Hey bariume -- if you don't mind me asking, where will you start fellowship next year? I understand if you want to stay anonymous. Are there any good fellow organizations that you know of that would be worth joining? Also, what texts have been recommended to you as good reading starting as a first eyar fellow?
With regards to the question about why I chose GI over Cardiology, 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 at my medical school, a guy named 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) 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 diagnose and manage a variety of diseases in a very minimally invasive way.
EP offers some neat procedures, and you do have some younger patients with rhythm abnormalities, but primarily deals with an older population and is rapidly becoming EF<30% needs ICD.
Endoscopy is a modality whose "scope" is boundless. As bariume has well detailed, there are more amazing developments in endoscopy on the horizon, and more beyond that. I just find endoscopy (as a modality) really compelling 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.
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. On balance, 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.
As discussed previously, 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. 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 3rd and 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.