GI vs. Cardiology

as a first year GI fellow who originally liked cardiology, i see the difference as such:

GI:
* money is great in private practice. colonoscopies, gi bleeding, hep c, etc. makes for great patient base.
* a greater variety of procedures: EGD, colonoscopies are very different, as are 24 hour ph monitoring, manometry, liver biopsy, etc. and the procedures have greater variation in therapeutic intervention: stenting, dilation, cautery, injection, biopsy, mucosal resection, ercp, eus with FNA, etc.
* better lifestyle overall
* closer to gen med - more variety. it's not just the heart. the liver is very different from pancreas, which is very different from stomach, esophagus, etc.
* greater variety of pathophys: autoimmune, infectious, neoplastic, congenital, endocrine, etc all affect GI and are common. cardiology is largely ischemic.

CARDS:
* sexier in layman's eyes
* interventional cardiology makes marginally more than GI (though non-invasive does not)
* more specialized, less gen med (some people like this)

hope this helps

Good question.

Jay C makes a lot of excellent points, and really emphasizes the diversity in pathology and procedures that GI offers.

Let me begin by saying that I would have been happy doing GI or Cardiology. I enjoy both fields tremendously.

What led me toward GI began 4th year of medical school.

I did a GI elective with one of the most dynamic people I know, a former Chief Resident and GI fellow at Parkland who was faculty when I was at Louisville for med school -- Whitney Jones. He amazed me with his encyclopedic knowledge of Medicine along with his broad array of procedural skills and willingness/ability to innovate with the endoscope. He practices as an "Advanced Therapeutic Endoscopist", skilled in ERCP, EUS, and other therapeutic upper and lower endoscopic procedures. What impressed me the most about him was his easy going nature and his amazing knowledge base about multiple fields in medicine.

I also happened to do an away rotation on the CICU at the Cleveland Clinic my 4th year and had Eric Topol as my attending for one month.

Suffice it to say, I was fortunate to have some pretty amazing role models.

Beginning intern year, I thought for sure I was Cardiology bound. However, during the course of that year, I began to realize some different things. First, a LOT of Internal Medicine is Cardiology, as most of your patients are 50 or above and therefore have CAD until proven otherwise

In other words, I think you can develop a pretty good feel for a lot of the issues Cardiologists deal with on a daily basis as a Medicine resident.

Cath, intervention, IBD, liver disease, endoscopy, GI bleeders, arrhythmia, valvular disease -- it will all get to be the same after a while.

My thought process went like this:

I like procedures. With endoscopy, you can actually see what you're doing, which is very appealing to someone like me. With cath, you're looking at a fluoro image of a wire and a catheter. It didn't seem quite as fulfilling (to me, that is). I would go back to the lab with my patients getting PCI when I did CCU as a resident (to observe of course) earlier this year and thought I would hear angels sing when the interventionalist got the wire past the lesion. Instead, it didn't do much for me. And all along I thought I wanted to do intervention. With endoscopy, you can see what you're doing as well as utilize some pretty amazing techniques (ERCP and EUS) to manage a variety of diseases in a very minimally invasive way.

EP offers some neat procedures, but primarily deals with an older population and is rapidly becoming EF<30% needs ICD.

Endoscopy is an amazing modality whose "scope" is boundless. There are many amazing developments in endoscopy on the horizon, and more beyond that. I just find endoscopy (as a modality) really fascinating and want to advance its application further. Sure, drug-eluting stents are the newest thing and are pretty amazing but PCI in Cards just wasn't as interesting to me in the long run.

As Jay C touched upon, there is a lot more diversity in pathology and in organ systems encountered in GI than in Cards. Obviously, the heart impacts and is impacted by other organ systems. But by virtue of dealing with the tubular gut, pancreas and liver, you are dealing with much of Medicine as well. So you can and must still be a good internist, particularly with Liver and IBD patients.

As I progressed thru intern year, I realized that I wanted to deal with patients from a variety of age groups, young and old alike. GI offers that chance in abundance -- older folks with malignancies, younger folks with IBD, and a spread of ages as a whole. Sure, there are 40 year olds with CAD and the EP guys occasionally see patients in their 20s-30s for EPS, but for the most part, Cardiologists deal with an older population. I wanted to see more than just old folks, and be able to impact patients at an earlier age in their life.

I also like the idea of being a true consultant in GI. I come in, make my recommendations, determine if a procedure is necessary, and follow the patients as needed. I don't amass a large inpatient service that consumes valuable time and resources, and can focus more on procedures and clinic. However, I still go to the hospital for consults and procedures, so I still get to be an inpatient doctor of sorts. And with clinic, I still get to develop long term relationships with my patients.

So for me, endoscopy, the variety of pathology, getting to see a broad age range of patients including a lot of younger patients, and the chance to be a consultant, were the most appealing aspects of GI and are what eventually led me to chose the field.

I'm 29 and enjoy critical care now -- I love it and it's pretty damn fun. But I can promise that at 55, critical care won't seem as fun anymore. But that's just my opinion. But I think I'm pretty realistic. Sure, there will be a high level of stress and a rush from stopping bleeding or extracting the stone in a pt. with cholangitis, but I can do fewer of those types of cases when I'm older. Cardiologists can't just walk away from critical care very easily, unless their partners take up the slack. I do hear of the occasional Cardiologist making good money reading ECHOs day and night, but that would sound boring too.

The bonus about GI -- incomes that are amongst the top in Medicine right now with a comparatively better lifestyle than Cardiology. Even if you don't do intervention, you're still taking call with your group, and Cardiologists do get called in at night much more often than GI docs do at all stages of practice. And as Jay C pointed out, the interventional Cardiologist does marginally better than a busy GI, with an important difference in lifestyle.

GI docs are very busy during their work day, and night call can be busy but is different than that for a Cardiologist. Usually, the GI doc is called in as a consultant to do a procedure and to make recs. Many times, like with bleeding, the procedure can even wait till the AM. The Cardiologist is called in to see, evaluate, and admit the patient in conjunction with whatever diagnostic or therapeutic procedures that will be done, and then follow that patient as the primary physician in house. The nature of the call is therefore very different.

One thing about colons -- I think doing them day in and out would get boring as well. You could make a damn good living doing colons all day all night. I want to do Advanced/Therapeutic Endoscopy, but I think a good Gastroenterologist is a consultant first and a proceduralist second, offering management recs and a procedure as needed, not just a scope-jockey. From that standpoint, you can make your practice as diverse as you want, or you can do scopes all day. And you can always do more colons to pay the bills.

There is no danger in colons being "lost" to other fields. If anything, other docs doing colons will free up the screening burden from GI docs and allow them to do more procedures for biopsy or therapy, which pays better. I wouldn't worry about surgeons or FPs stealing mass quantities of colons -- their time is better spent doing other things, and surgeons don't want to bite the hand that feeds them. But again, most GI docs wouldn't lose sleep over having the screening burden picked up by others.

I think the most important thing for you to do is gain exposure to both fields as a 4th year. Make sure in your Cards rotation that you get exposure to consultative cardiology, CCU, ECHO -- all that one does, and try to get in to observe cath/interventions. On GI, see as many consults as you can, go to the Endoscopy suite, and go to clinic.. That will give you a good feel for both fields. Then, as an intern and resident, do electives in both fields scheduling them depending on when you'll be applying to fellowship (2nd or 3rd year) to see the same things more in depth.

As I said at the beginning, both are great fields, and you can't go wrong with either one.

Email me if you have more questions or thoughts.

How does renal compare?

So what do you think of the Capsule Endoscopy that's coming along now? I know it's more for GI bleeds, esp small bowel ones, but sooner or later as they perfect I think they will use it as a more general screening alternative to scopes. I read a few months ago the cost would be considerably cheaper because all you do is have the patient swallow the pill and then they poop it out several hours later, no need to scope them. Only if there is a question or problem is the patient then scoped. I'm inclined to think insurance companies would be all over this (for better or worse), as the cost(if I remember right) was projected to be 400-600 vs 2000-3000 for scopes. Of course this all depends on how well the can perfect it which will still take some time. But one GI doc told me expects salaries to go down once they get capsule endoscopy going, and scopes would go down in number (which would suck because I do like the procedural part of GI a lot).
However it would make lifestyle better in my opinion as you can just sit there and look at the videos like a Cardiologist reading echos. But then many others will also try to read them FPs, IMs and maybe radiologists(??). Again this is all dependent on how well they can get it to work.

Interesting point there IW, I am not all that familiar with capsule endoscopy but I would supect that the need for biopsies would still require a scope with the proper harvesting tools. Would like to hear our colleagues above thoughts.

All the best.

Sorry for the delay in answering, vitaminj.

There was a good article in a recent issue of Resident Physician from May, I think. I have the issue and will re-read it to post the major points. I'm in the middle of moving apartments, and my wife did a number on my desk where I had a bunch of journals stacked but I know exactly where it is, just need to unpack it.

The long and short of it is that GI docs have been the biggest proponents of capsule endoscopy. To that end, don't worry about the capsule endoscope supplanting the fiberoptic endoscope. Most lesions of clinical significance are within the reach of the fiberoptic endoscope, therefore allowing for diagnostic and therapeutic manuevers that are the real art of endoscopy. So the vast majority of the time, a conventional endoscopic evaluation is all a patient needs. Capsule is employed when standard fiberoptic endoscopy has failed to find a lesion or source of the problem -- e.g. AVMs farther down the small bowel. So you've found AVMs at a point where standard endoscopes can't reach, therefore they're not amendable to heat therapy or whatever. You resign yourself to the fact that the patient has a slow chronic bleed from AVMs and you put the patient on iron. I suppose if the AVM bleeding is significant enough and is confined to a particular region, you could refer them for surgical resection, but that situation seems pretty silly and would likely never be the case clinically.

One of the major issues the article I quote above cites is the issue of localizing the lesion in the small bowel. Past the duodenum, most of the small bowel looks the same, so you have no real way (with current techology) of knowing exactly where a lesion is located, so even if you want to do something about it, where is it? If you worry about malignancy, that's pretty rare past the duodenum anyway. So what are you going to do with a lesion you've "found" but can't "find" again, if you catch my drift. Another issue is the type of images generated (not the greatest) but that's a technology issue that I'm sure will be resolved.

As for who reads the 2 hours or more of images generated by the capsule, I believe that will still be in the purview of GI docs. Sure, internists, radiologists, and surgeons can be trained to read the images, but it will be the GI doc who will more than likely have the most to gain from a time and reimbursement standpoint when the $$$ issue is worked out. Reimbursement schedules are optimized for each field -- so it pays for a radiologist to read films or do their procedures, an internist to see patients or admit pneumonia or CHF, or a surgeon to be in the OR, not reading capsule endoscopy films. The internist won't have the time to spend 2 hours reading a film just to refer a patient on for further therapy, and GI docs will have access to and control these patients before the surgeon or radiologist, so they'll order and interpret the procedure before those two fields will. Also, say you find a a confusing lesion -- a GI doc probably has the most experience in interpreting what the mucosa means clinically, and therefore recommending initial therapy. Bottom line, the ball stays firmly in their court.

In the end, capsule endoscopy will be an addition to the current endoscopic armamentarium. I suppose the situation might arise where everyone gets a capsule first, then if something is found where a standard endoscope can reach, the patient then undergoes a second procedure, but why have to pay for two procedures when the standard (fiberoptic endoscopy) is safe, time efficient and effective in trained hands anyway? IF you find something on capsule where a standard endoscope can reach, they'll need one anyway. For these reasons, I don't forsee capsule endoscopy in any way supplanting the need for standard endoscopic procedures. If anything, if ever used for screening, it will find more lesions to go after where and when they can be reached with standard endoscopy.

I'll be sure to find that article -- it is much more succinct and eloquent than my rambling above

Is the capsule endoscopy approved?

well crap (hey, no pun intended!)

I've been intent on cardiology since 3rd year of med school. Did all the research and chose my residency program based on their cardiology fellowship program, got set up with research, the works, blah blah

Damned if 11 months into my intern year, suddenly I am wavering on cardiology, for the first time ever, and seriously considering GI. I never had any interest in GI until this month. I have no idea what happened.

Looks like I'll be taking a hospitalist year instead of applying for cardiology this year until I figure out what I want. Why me?

Can anyone else speak about the differences in lifestyle between the two fields (as it pertains to call and average number of hours worked/week?)...not too concerned about salary b/c they both make more than I will ever need.
Thanks.

After being in the real world for enough time now, as a resident and as a fresh attending, I was thinking in the same ways. Who has the easier lifestyle, which fellowship would be better, etc? It took years to realize this, but:

1. NO ONE has an easier job than anyone else.

2. Everyone's jobs are difficult. Doesn't matter whether you do Cards, Nephro, IM, Heme onc, GI. NO ONE has it easier than anyone else. Period.

3. All of us are in the hospitals after 6,7,8 pm. Cards, GI, IM-we all have to come in the middle of the night. There's always some type of emergency in the ICU that requires you to come in. You're never absolved of this responsibility-or you lose privileges to work at a hospital.


So what do you do? Go after something you enjoy, please. It's the only way to survive and practice forever.

Ash MD said:

After being in the real world for enough time now, as a resident and as a fresh attending, I was thinking in the same ways. Who has the easier lifestyle, which fellowship would be better, etc? It took years to realize this, but:

1. NO ONE has an easier job than anyone else.

2. Everyone's jobs are difficult. Doesn't matter whether you do Cards, Nephro, IM, Heme onc, GI. NO ONE has it easier than anyone else. Period.

3. All of us are in the hospitals after 6,7,8 pm. Cards, GI, IM-we all have to come in the middle of the night. There's always some type of emergency in the ICU that requires you to come in. You're never absolved of this responsibility-or you lose privileges to work at a hospital.


So what do you do? Go after something you enjoy, please. It's the only way to survive and practice forever.

Click to expand...

Well said.

Everyone says "Theres nothing wrong with factoring lifestyle into your decision"... and then asks which pays more, or has less hours - GI or Cardio. Not that theres anything wrong with that...

Whichever field you go into, you can work as little or as much as you want, or make as much money as you want. But something will have to give. - Work shorter hours?... Internists will send you the bogus consults, because they dont want to have to rely on you when things go sour.

Otherwise, you're stuck with call.

If you have your heart set on one field, and suddenly you find yourself drawn to something else. Think about why. Many times, we become starry eyed when we "discover" a new field... but what might really be attracting our attention is a good attending, or teaching, or facilities - something that's specific to the environment, and not the specialty itself. And that sort of stuff may change. (as will reimbursement)

So, do whatever blows your hair back.

Yeah, Im a med student, but Im older, and this is my second career. And I say that, because it seems like (in the real world) many people who ask these sorts of questions are those that have never actually had a real job.

Capsule endoscopy currently is not used for routine screening for colonic polyps. I don't know if you ever read one, but the rate of colonic polyp detection is rather poor. I am sure as technology gets better, they maybe used for routine colonic screening, however, the more you screen, the more "abnormality" you will pickk up = more colonoscopies.

Same argument goes for virtual colonoscopy which all these people think is going to take over traditional colonoscopy.... Personally, it is one of the most inefficient and tedious scan that you will ever read (i have seen a few with the radiologists) and there are so many problems with it... for example, in order to "cover" themselves, radiologist always, always over call things. Things that look like a piece of small stool, they will say, can't rule out colonic polyps.... so what do the primary care doc do? they order a colonoscopy. The patient is pissed to go through the same prep for a second time, and we found nothing. We have already seen more colonoscopy referral for "abnormality" detected during virtual colonoscopies.

In short, none of these "fancier" screening method is going to take over the tradional colonoscopies...matter in fact, its probably adding more dollars to the healthcare and more work for us in the future.

BTW, capsule endoscopy is probably one of the most profitable test that a GI doc. can bill..., and it is so easy..., i suppose I won't mind reading more of those.

Also, don't worry about other people (radiology, FP, IM et...), they won't know that they are looking at nor do they know what to do with it.

impatiently waiting said:

So what do you think of the Capsule Endoscopy that's coming along now? I know it's more for GI bleeds, esp small bowel ones, but sooner or later as they perfect I think they will use it as a more general screening alternative to scopes. I read a few months ago the cost would be considerably cheaper because all you do is have the patient swallow the pill and then they poop it out several hours later, no need to scope them. Only if there is a question or problem is the patient then scoped. I'm inclined to think insurance companies would be all over this (for better or worse), as the cost(if I remember right) was projected to be 400-600 vs 2000-3000 for scopes. Of course this all depends on how well the can perfect it which will still take some time. But one GI doc told me expects salaries to go down once they get capsule endoscopy going, and scopes would go down in number (which would suck because I do like the procedural part of GI a lot).
However it would make lifestyle better in my opinion as you can just sit there and look at the videos like a Cardiologist reading echos. But then many others will also try to read them FPs, IMs and maybe radiologists(??). Again this is all dependent on how well they can get it to work.

Click to expand...

Nothing more satisfying then stopping a bleeder at 2:00 AM and watch that BP stablize...

Fixing a post surgical tracheoesophageal leak after two failed surgical repaired ranks pretty high too....

I love my job

howelljolly said:

Well said.

Everyone says "Theres nothing wrong with factoring lifestyle into your decision"... and then asks which pays more, or has less hours - GI or Cardio. Not that theres anything wrong with that...

Whichever field you go into, you can work as little or as much as you want, or make as much money as you want. But something will have to give. - Work shorter hours?... Internists will send you the bogus consults, because they dont want to have to rely on you when things go sour.

Otherwise, you're stuck with call.

If you have your heart set on one field, and suddenly you find yourself drawn to something else. Think about why. Many times, we become starry eyed when we "discover" a new field... but what might really be attracting our attention is a good attending, or teaching, or facilities - something that's specific to the environment, and not the specialty itself. And that sort of stuff may change. (as will reimbursement)

So, do whatever blows your hair back.

Yeah, Im a med student, but Im older, and this is my second career. And I say that, because it seems like (in the real world) many people who ask these sorts of questions are those that have never actually had a real job.

Click to expand...