Why Trust, Access, and Relationships Drive GI Growth
By Dr. Charles Accurso and Praveen Suthrum
Imagine two GI practices in the same market.
Both have good physicians. Both perform high-quality procedures. Both have access to an ambulatory surgery center. Both participate in pathology and anesthesia. Both are clinically competent. From the outside, they may look similar.
Ten years later, one is thriving and the other is struggling.
The difference is not simply technology. It is not private equity. It is not marketing. It is not even the ASC.
The difference is that one practice understood something the other did not: the most valuable asset in gastroenterology is not a building, a scope, a lab, or a contract.
It is trust.
Trust with patients. Trust with referring physicians. Trust is built over years of doing the right thing. Trust reinforced by access, follow-up, availability, honesty, and continuity.
Everything else sits on top of that.
The ASC monetizes trust. The recall system activates trust. The referral network amplifies trust. Technology can scale trust. But trust itself is the asset.
Many GI practices do not fully realize how much of this asset they already own.
Before You Build Something New
Most conversations about the future of GI quickly move toward what comes next: AI, virtual care, microbiome science, metabolic health, liquid biopsy, robotics, employer models, new payment models, and new revenue streams. All of those matter. Some may eventually reshape gastroenterology in profound ways.
But before a GI practice looks outside itself for growth, it should ask a simpler question:
What value is already sitting inside the practice that we have not fully activated?
Most established GI practices already have more than they realize. They have long-term patient relationships, established referral networks, recall lists, ASC access or ownership, pathology, anesthesia, infusion, APPs, clinical data, payer relationships, hospital relationships, clinical credibility, and community reputation.
Some of these assets are visible. Others are invisible. The invisible ones may be the most important.
No matter how sophisticated the business model becomes, growth still begins with patients coming through the door. No patients, no procedures. No patients, no pathology. No patients, no anesthesia. No patients, no infusion. No patients, no clinical trials. No patients, no meaningful data asset.
Every growth strategy depends on the same foundation: Do patients trust you enough to come? Do referring physicians trust you enough to send them? And can your system actually receive them when they do?
The Asset Behind Every Other Asset
When GI physicians talk about practice value, they often begin with the ASC. Understandably so. ASC ownership transformed the economics of gastroenterology. Then came pathology. Then anesthesia. Then infusion. These ancillaries helped make GI one of the most attractive and entrepreneurial specialties in medicine.
They still matter enormously. In some settings, ASC, anesthesia, and pathology economics can materially change a gastroenterologist’s income. Depending on structure, volume, payer contracts, ownership, and state regulations, these assets can produce significant incremental value without the physician needing to personally do more clinical work.
But there is a catch.
Those assets only work if patients keep coming.
A beautiful ASC without volume is not a strategy. A pathology arrangement without specimens is not a business. An anesthesia model without procedures is just overhead. An infusion program without the right patients, authorization workflows, nursing capacity, and clinical management structure will not perform.
The tree matters. But only if there is fruit.
That is why the first asset is not the ASC. The first asset is the patient relationship.
The Money Falls Off the Tree
During one of our working discussions, Dr. Charles Accurso said something that should probably be written on the wall of every GI practice:
“The money falls off the tree when the right things are done.”
That line sounds simple. It is not. It reflects decades of practice wisdom.
Do the right thing for the patient. Be honest. Be available. Communicate well. Follow up. Make sure the patient feels cared for. Make sure the referring physician knows you handled the problem. Build a reputation for judgment, responsiveness, and integrity.
If you do those things consistently, the economics follow.
Patients come back. Families come back. Referring physicians keep calling. Procedure volume grows. Ancillaries become more valuable. Reputation compounds.
This is not sentimental. It is strategic.
Healthcare businesses often try to optimize the fruit while neglecting the tree. But in GI, the tree is trust.
The Recall System Is Not Administrative
Few systems reveal this better than recalls.
Most practices think of the recall system as an administrative task: a letter, a text, a reminder, a scheduling workflow. That view misses what is really happening.
The recall system is the practice remembering the patient.
And patients like being remembered.
At this stage in his career, Charley estimates that a large portion of his procedures are not from new patients. They are from patients he has known for years, sometimes decades. Patients on whom he has performed multiple colonoscopies over twenty or thirty years. Patients who return because they received a reminder.
Maybe a letter. Maybe a text. Maybe a call.
The form matters less than the signal.
The signal is: We remember you. You matter. You are not falling through the cracks.
That is why recalls are not just about volume. They are about continuity and cancer prevention. They are about surveillance and risk reduction. They are about the business foundation of the practice.
A weak recall system is not a minor administrative gap. It is leakage from one of the most valuable assets the practice owns.
Recalls Can Be the Entry Point Into Modernization
A recall project may look small. It is not.
It may become the first practical step in modernizing the practice because it is narrow enough to pilot, measurable enough to prove value, familiar enough for physicians to understand, and connected to something every GI practice already cares about: patients who should return.
A recall pilot can show the practice what automation and AI can do without asking everyone to believe in a massive future transformation. The practice can measure how many patients were due, how many were contacted, how many were scheduled, how many converted to procedures, how much staff time was saved, how much volume was recovered, and how many patients were protected from falling through the cracks.
Once a practice experiences that, the conversation changes. The question is no longer, “Should we use AI?” The question becomes, “Where else are we doing manual work that a better system could handle?”
That is when the practice naturally begins looking at prior authorization, eligibility, scheduling, access, patient communication, documentation, and revenue cycle.
In that sense, recalls are not merely a workflow. They are a gateway.
Every Recall Is a Relationship That Did Not Disappear
A patient who returns after five years for surveillance is not merely a scheduled procedure. That patient represents a relationship that survived. They remembered the physician, or the system remembered them. Either way, continuity was preserved.
This is especially important because established patients are very different from new referrals. A new referral requires referral trust, intake, scheduling, records, clinical evaluation, patient confidence, and conversion. An established patient already knows the practice. They know how they were treated. They know whether they felt respected. They know whether the physician was present. They know whether the team followed through.
Bringing that patient back is often easier than generating a completely new patient relationship.
That does not mean new patients are less important. It means existing patient relationships are strategic assets, and in many practices, the recall system is the mechanism that activates them.
Access Is Trust Expressed Operationally
If trust is the hidden asset, access is how trust becomes visible.
Patients may love a physician. Referring doctors may respect a practice. But if patients cannot get in, trust erodes.
Access is not just an operational metric. Access is trust expressed operationally.
Consider a common example. A 50-year-old patient develops persistent dyspepsia. The primary care physician is not alarmed but thinks an EGD may be reasonable. From the PCP’s perspective, this may be a routine referral. From the patient’s perspective, it may feel like cancer.
The patient is scared. They call the GI practice.
If the answer is, “The next available appointment is in three months,” something happens immediately. The patient calls the referring physician. The referring physician calls another gastroenterologist. The referral goes elsewhere.
Not because the other gastroenterologist is better. Because the other gastroenterologist is available.
Now imagine the opposite. The patient is seen quickly. The endoscopy is scheduled within a reasonable timeframe. The patient receives reassurance. Two weeks later, the patient sees the primary care physician again and says, “Thank you for sending me there. They saw me right away. They did the test. I’m okay.”
That moment builds the referral relationship more powerfully than any brochure, lunch, or marketing campaign.
The referring physician learns: When I send patients there, they are taken care of.
That is growth.
Access Can Create 10–20% More Volume
When we asked how much improved access could realistically increase volume, Charley estimated that depending on the practice and baseline volume, there is no reason to think it could not be 10% to 20%.
That is a remarkable point.
Not from acquiring another practice. Not from launching a new service line. Not from spending heavily on marketing. From making it easier for the patients who already need you to enter the system.
But access must be understood correctly. Access does not only mean a clinic appointment. It means urgent office access, referral access, procedure access, recall access, communication access, and follow-up access.
If a patient is afraid they have cancer, seeing them in the clinic is only part of the solution. The system must also have a way to get them scoped promptly when appropriate. That requires operational design: open slots, triage rules, physician alignment, ASC flexibility, staff coordination, and anesthesia coordination.
This is why access is not just scheduling. Access is strategy.
The Access Operating Model
Most GI practices will immediately say, “Our schedules are full.”
That may be true. But it does not mean access cannot be improved. It means access must be designed.
Access is not solved by telling physicians to work harder. It is solved by designing capacity more intelligently. The goal is not to create more hours in the day. The goal is to stop treating every patient request as the same kind of demand.
A modern GI practice should redesign access across five lanes.
The first lane is the urgent referral lane. This is for patients whom referring physicians are worried about now: bleeding, dysphagia, weight loss, abnormal imaging, severe pain, concerning labs, or cancer anxiety that requires timely evaluation. These patients need a clear path into the practice. That may mean protected urgent slots, a dedicated referral line, a physician-to-physician escalation pathway, or an AI-supported urgent intake process.
The second lane is the recall lane. These are patients the practice already knows should return. They should not compete randomly with every other appointment request. They should move through a disciplined outreach and scheduling process. A recall patient is not just another name on a list. It is a known relationship that needs to be reactivated.
The third lane is the cancellation recovery lane. Every cancellation is hidden capacity. In many practices, cancellations are filled manually, slowly, or not at all. An intelligent waitlist, supported by automation or AI, should identify the right patient for the opening, contact them immediately, confirm the appointment, and update the schedule. This is one of the fastest ways to recover capacity without adding a physician or APP.
The fourth lane is the APP triage lane. Not every patient needs the physician first. APPs can support urgent symptom review, post-procedure follow-up, GERD, IBS, fatty liver monitoring, constipation pathways, biologic checks, and recall-related visits when protocols are clear. APPs should not simply absorb overflow. They should be integrated into designed care pathways.
The fifth lane is the procedure-readiness lane. Some patients are already ready to move quickly into a procedure slot if one opens. The practice should know who they are, whether insurance is verified, whether prep instructions are complete, whether clearance is done, and whether they can come on short notice. This makes procedure access more dynamic rather than entirely dependent on fixed scheduling.
Access redesign is not a scheduling project. It is a physician-alignment project. If physicians do not protect urgent slots, if APP roles are unclear, if cancellation lists are passive, if the ASC cannot flex when needed, or if referral urgency is not triaged consistently, the access problem will continue.
A practice that improves access does not merely fill more appointments. It captures demand that was already present but leaking elsewhere.
What Not To Do
Access should not be solved by simply overbooking physicians until they burn out. That is not access design; that is exhaustion disguised as productivity.
Do not allow urgent slots to be casually consumed by routine follow-ups. Do not let cancellations sit open because no one owns the waitlist. Do not make PCPs fax referrals into a black hole. Do not ask APPs to absorb overflow without clear protocols. Do not assume every patient request belongs in the same scheduling queue. Do not design a system that depends on one heroic physician staying late every day.
Heroics may work temporarily. They do not scale.
Access requires design, discipline, physician alignment, and measurement.
Referral Networks Still Matter
Healthcare consolidation has changed referral patterns. Primary care physicians are increasingly aligned with hospital systems, payers, or large groups. In many markets, PCPs are encouraged—or pressured—to refer within the system.
That makes many independent GI practices nervous. Understandably.
But referral relationships are not dead. They are different.
A primary care physician may be given a list of preferred in-network gastroenterologists. But when a patient has acute abdominal pain, bleeding, weight loss, abnormal labs, or severe symptoms, the PCP often thinks practically: Who do I trust? Who will answer? Who will see this patient quickly? Who will take care of the problem?
That is where relationship still matters.
A practice that has built trust over the years can continue receiving referrals even when formal systems push otherwise. But that trust must be earned repeatedly. It is not enough to have once had the relationship. You must still perform.
The referral network is not only a source of volume. It is a relationship asset. And like every relationship asset, it must be maintained.
What a Young GI Physician Should Do First
If Charley were advising a young gastroenterologist joining or building a practice today, his advice would be surprisingly old-fashioned.
Pull a list of the top thirty referring physicians. Then go meet them.
Not email. Not send a generic announcement. Not rely on the practice brand.
Meet them. Introduce yourself. Tell them you are there to provide a service. Then earn the relationship one patient at a time.
Because the referring physician’s first question will be simple: How was the visit?
If the patient says, “They listened,” “They explained things,” “They saw me quickly,” “They took me seriously,” or “They followed up,” the relationship strengthens.
If the patient has a poor experience, that referral source may disappear.
This is not a minor “soft skill.” It is one of the core business skills of medical practice. And it is not taught nearly enough.
The Skill We Underteach
GI training emphasizes knowledge, technique, judgment, safety, and procedural skill. It should. But one of the most important skills in practice is the ability to relate—to patients, families, referring physicians, staff, and partners.
A technically excellent gastroenterologist who cannot connect with patients will struggle. A brilliant physician who does not communicate well with referring doctors will limit growth. A practice that delivers excellent procedures but poor access will lose opportunities.
This is uncomfortable to say, but important: some of the most successful physicians are not successful merely because they are technically better. They are successful because patients trust them, referring physicians trust them, staff trust them, and the practice has systems that reinforce that trust.
Technology Should Remove Friction Between People
This is where AI and automation become powerful—not because they replace relationships, but because they remove friction around relationships.
Think about what makes Amazon work. Amazon did not simply sell products online. It removed friction from buying: search, click, pay, track, return, repeat. Every unnecessary step was questioned.
Healthcare needs a similar mindset without losing its humanity.
What are the friction points between a referring physician and a GI practice? Faxing records. Calling the office. Waiting on hold. Leaving messages. Unclear urgency. Manual data entry. Delayed scheduling. Lost paperwork. Poor follow-up communication.
Now imagine a different model. A referring physician has an urgent GI referral. They click one button. The relevant clinical information is pulled, structured, and sent securely. The GI practice receives the referral in the right queue. An AI-enabled intake system contacts the patient immediately. The patient is triaged. An urgent slot is identified. The referring physician receives confirmation. The patient feels cared for before they even arrive.
That is not technology replacing medicine. That is technology making the relationship work better.
And a referring physician who experiences that will not easily leave.
The practice that makes it easiest for the right patient to reach the right physician at the right time will win more than referrals. It will win trust.
The Future Is One-Click Referral
Today, many referral workflows still feel like they belong to another era: print, fax, call, wait, re-enter, scan, upload, clarify, repeat.
This is absurd.
The future referral relationship should be simpler. Not because medicine is simple, but because the administrative bridge should not be so hard.
A GI practice that makes referral easy becomes more valuable to primary care. A GI practice that makes urgent access easy becomes more valuable to patients. A GI practice that communicates clearly becomes more valuable to everyone.
This is where AI becomes practical—not as a shiny tool, but as connective tissue.
A one-click referral model may sound futuristic, but the underlying idea is simple: make it easier for the right patient to get to the right GI physician at the right time.
That is what referral relationships have always been about. Technology just gives us a way to do it better.
Ownership Is Not Optimization
Now return to the traditional assets: ASC, pathology, anesthesia, and infusion.
These remain highly important. For some practices, they are the most direct economic assets available. But there is a mistake practices can make: assuming that because they own or participate in an asset, they have optimized it.
Ownership is not optimization.
A practice may have an ASC but fail to optimize room utilization, block time, payer contracts, staffing, anesthesia coordination, procedure mix, urgent access, throughput, and patient experience. A practice may have pathology but fail to optimize payer arrangements, specimen flow, reporting turnaround, integration with clinical decisions, quality reporting, and patient communication. A practice may have infusion but fail to optimize biologic starts, prior authorization, patient education, medication tracking, scheduling, monitoring, and coordination with chronic disease pathways.
Many practices have also entered relationships with hospitals, private equity groups, ASC partners, anesthesia groups, or pathology partners. That can be valuable. But it can also create a subtle risk.
Once another party is involved, physician attention can drift. The practice may stop watching the numbers as closely as it did when it owned everything directly. That is dangerous.
The danger is subtle: once someone else is involved, physicians may assume someone else is watching the business.
That is how value leaks.
The best practices stay close to the economics. They do not abdicate responsibility. They keep asking whether they are getting paid correctly, whether contracts are current, whether operations are efficient, whether patients are moving smoothly, whether value is being left on the table, and whether physicians are still acting like owners.
Clinical Trials, Data, and the Partner Mindset
Some assets require a different kind of thinking. Clinical trials are a good example.
Many GI practices are interested in research, but not every practice has the infrastructure, protected physician time, staffing model, or operational mindset to build a research program internally. Historically, that meant many practices simply did not participate.
Today, the options are different. There are partners who can help practices activate clinical trials without forcing physicians to build the entire infrastructure themselves.
The same is true with data.
For many physicians, “data as an asset” still feels vague. The practical version is this: a GI practice has years of structured and unstructured information sitting inside its systems—diagnoses, procedures, pathology, medications, outcomes, notes, disease cohorts, and longitudinal patterns.
On its own, that data may be messy and unusable. But when cleaned, structured, protected, governed, and connected to research or life-sciences needs, it can become valuable.
This does not mean every practice should become a data company. It means practices should understand that data may become a new ancillary, but only if governance, ownership, privacy, partnerships, and use cases are handled carefully.
The question of who controls the data must be clarified early. Is it the practice? The physicians? The EHR vendor? The hospital partner? The investor? The answer matters.
Data strategy should never begin with a vendor demo. It should begin with ownership, governance, trust, and purpose.
Being the Hub Does Not Mean Doing Everything
This is one of the most important mindset shifts for GI 2.0.
A GI practice does not need to build every capability internally. It does not need to build every clinical trial program, data platform, nutrition service, digital pathway, or AI capability.
But it does need to know which partners to trust. It needs to know which relationships to activate. It needs to understand how those partnerships fit into the patient journey.
The practice should own the clinical judgment, the patient relationship, the ethical responsibility, the trust, and the care pathway. It can partner around infrastructure, technology, analytics, research, patient engagement, nutrition, digital support, and specialized care models.
Being the hub does not mean doing everything yourself. It means coordinating what matters.
That may become one of the defining capabilities of successful GI practices in the next decade.
Patients Who Disappear
Every GI practice has patients who disappear. They miss follow-up visits, miss procedures, do not respond to recalls, cancel and never reschedule, or receive a diagnosis and vanish.
Sometimes that is appropriate. Sometimes the patient is reassured and does not need ongoing GI care. But sometimes the loop is not closed.
That matters.
A patient with an unusual lesion. A patient with Barrett’s. A patient with polyps. A patient with abnormal liver tests. A patient who no-shows after concerning symptoms. A patient who needed a repeat study.
If there is no system to identify and re-engage those patients, the practice is leaking care and value.
This is another place where automation can help. A missed appointment should trigger a workflow. A missed procedure should trigger a workflow. A failed recall should trigger a workflow.
Not to pressure the patient. To protect continuity. To document effort. To practice better medicine.
Technology, when used well, helps the physician be a better doctor.
The Underbuilt Opportunity in Chronic GI
When we discussed chronic GI conditions, Charley made an important observation: GI does a relatively good job managing IBD longitudinally. The specialty understands that IBD requires ongoing care, medication management, monitoring, infusion, imaging, labs, and follow-up.
But many other GI conditions are still managed episodically: IBS, GERD, dyspepsia, fatty liver, obesity-related digestive disease, chronic constipation, motility issues, and microbiome-related concerns.
Some patients do not need ongoing GI follow-up. Some should return to primary care. GI should not try to own everything.
But there are clearly areas where structured pathways could improve care and create value.
Fatty liver is one of the most obvious. With metabolic disease rising and GLP-1 medications reshaping care, fatty liver sits directly at the intersection of GI, obesity, primary care, endocrinology, cardiometabolic health, and long-term risk management.
Chronic constipation is another underdeveloped area. Motility testing, anorectal manometry, biofeedback, and structured treatment pathways remain underutilized in many settings.
Microbiome science is still evolving, and GI must be careful not to outrun the evidence. But patient demand is already there. Companies are already building around it.
So the question for GI is not whether these areas will grow. The question is whether GI practices will help shape them scientifically and clinically—or watch others define them.
Do Not Compete With Your Ecosystem. Coordinate It.
One caution matters: GI practices should not blindly try to capture every adjacent opportunity. That can create conflict with referring physicians.
For example, many primary care physicians are now deeply involved in obesity care and GLP-1 prescribing. If a GI practice tries to take all obesity management away from PCPs, it may damage the very referral relationships that support the practice.
The better question is: What should GI own? What should GI coordinate? What should GI partner around? What should GI refer back?
This is a more mature model.
GI does not need to become everything. But GI should not become narrow either. The future practice will likely be defined by intelligent coordination—not hoarding, not passivity, but coordination.
The Three Assets That Matter Most
After all this discussion, the chapter can be summarized simply. The assets most practices already own fall into three categories.
Relationship assets create patient flow. These include patient trust, referral relationships, community reputation, long-term continuity, and established referral networks.
Economic assets monetize patient flow. These include ASC, pathology, anesthesia, infusion, clinical trials, and data partnerships.
Leverage assets multiply capacity. These include recalls, access systems, workflow redesign, automation, AI, referral platforms, APPs, and operational leadership.
The mistake is to focus on the second category while neglecting the first and third.
Economic assets matter. But relationships create the volume. Systems preserve the volume. Technology scales the systems.
That is the real sequence.
The 60-Minute Growth Audit
Before building a new revenue stream, the leadership team should run a practical growth audit.
Do not start by forming a committee. Start by pulling reports.
Bring the administrator, managing partner, scheduling lead, billing lead, and one physician champion into the room. Put the data on the table. Ask where value is already leaking.
First 15 minutes: referral and access. Review the top 30 referring physicians, urgent appointment availability, referral-to-scheduled time, referral-to-seen time, cancellation fill rate, and procedure access for urgent patients. Ask: Who sends patients today? Who used to send patients but no longer does? How easy is it for a PCP to get an urgent patient seen? How many patients are lost because access is too slow?
Next 15 minutes: recalls and leakage. Review the overdue recall list, procedure volume by source, no-show rates, missed procedures, failed outreach, and recall conversion. Ask: What percentage of procedures comes from existing patients? How many patients are overdue? What happens after the first failed outreach? Who owns recall performance?
Next 15 minutes: economic assets. Review ASC, anesthesia, pathology, and infusion performance. Ask: Are contracts current? Are operations efficient? Are rooms utilized well? Are physicians still paying attention like owners? What value is being left on the table?
Final 15 minutes: leadership and action. Choose one 90-day project. Assign one owner. Define one measurable outcome. Do not leave with a broad intention. Leave with an operating commitment.
Examples of 90-day projects include:
- improve cancellation fill rate
- activate a dynamic recall workflow
- create urgent referral slots
- build a top-30 referring physician outreach plan
- automate one prior authorization workflow
- improve no-show recovery
- review ASC block utilization
- evaluate clinical trial or data partnership opportunity
The purpose of the audit is not to solve everything. It is to reveal where the practice already has value but lacks operational focus.
The Real Growth Strategy
Most GI practices do not need to start with something exotic.
They need to fully activate what they already have: trust, access, referrals, recalls, existing patients, existing assets, existing data, existing relationships, and existing reputation.
The future of gastroenterology will not be built only on AI, private equity, diagnostics, or digital care. It will be built on something much older: the relationship between doctor and patient, the relationship between specialist and referring physician, the ability to be available when needed, the discipline to follow up, the wisdom to do the right thing, and the systems to make all of that reliable.
That is what many practices already own.
They just need to see it.
And once they do, a larger possibility emerges.
If GI practices strengthen trust, improve access, activate recalls, protect referral relationships, optimize existing assets, and build the leadership capacity to keep their heads out of the boat, they earn the right to ask a larger question:
What should GI become next?
Should GI remain primarily a procedure specialty?
Or should it become the coordinator of digestive health itself?
That is where we go next.
Trust creates volume. Systems operationalize trust. Technology scales trust.