Gastroenterology

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bariume

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Is anyone here thinking about/applying/ or going to train in Gastroenterology? Please share your thoughs on the field. This season's application run for 2005 is nearing its end. GI typically starts their application process very early in July.

Here are a few links for those interested.

Nice article on tips for applying for fellowship:
http://www.acponline.org/journals/news/jul-aug00/fellowship.htm

List of Training Programs

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no bites?

well if anyone is interested, you can PM me.
 
bariume,

Do a search in the IM forums for Gastroenterology, GI, or GI vs. Cards, or some variation thereof. There has been a lot of discussion on your question(s) that would probably be of interest. I will be a GI fellow at Parkland in Dallas starting 7/04 after finishing my residency here. Thought I was going to be a Cardiologist, but changed during intern year. Happy to answer any questions you might have.

Take care:)
 
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yes, thanks. I will be a fellow too. I was just hoping to start some discussion for those interested in the application process.
 
hey guys, congrats on getting the fellowship...i'm hoping to be in the same boat too, but i'm only an MSI, so still a long road to reach where you guys are...

i have some questions?

1) Do you have any worries that radiologists will be taking over some of the procedures done by GI docs?

2) What made you decide GI over cards?
 
I once thought that scanning the colon from the outside could one day replace colonoscopies too, but I just don't think that scanning will ever be senstive enough to pick up some of the villous lesions. And of course, if you see anything, you will still need to go in and biopsy it. Maybe that camera thing will pick up, but I think that GI docs are more likely to pick up interpreting those over radiologist. You already see GI docs doing endoscopic ultrasounds to pick up lesions in the esophagus that other scans cannot pick up, I don't see why some of the new imaging modalities that they are thinking about doing couldn't be picked up by GI docs too. Lot's of people seem to have difficulty deciding between GI and cards since both are so procedural based. My advice would just keep an open mind during med school, it's great if you know that you are doing medicine for sure but you should also consider other specialties if you are very procedurally oriented (like surgery), and if you do end up choosing medicine, doing fourth year electives in those subspecialties should help you cement your decision.
 
I would have to agree with ckent. Endoscopic procedures are not going to be phased out by radiology anytime soon. In fact, Gastroenterology is one of the fields where technology has improved the diagnostic and therapeautic capabilities tremendously over the last decade. Endoscopic ultrasound is becoming more widely available, and some imaging techniques done by the endoscope are now so good that they can even replicate the histologic level without a biopsy. Some of the other procedures that are up and coming are chromo-endoscopy (using dye to coat the mucosa for better visualization of irregularities and lesions), endoscopic fundoplication, endoscopic assisted laser treatment of Barrets, and endoscopic piecemeal resection of gastric/duodenal ulcers. As you can see, this field is taking off tremendously.

Dirtybob, i think it is the perfect time to think about these fields as an MS1. Because with the increasing competitiveness of GI and cardiology, it is vital to start early. The earlier you begin seeking out information, the earlier you can make a decision and then start tailoring your medical education to prepare you for this field. Most people applying to GI these days have known they wanted to be in the field very early on.
 
As virtual colonoscopy becomes a mainstream medical test, gastroenterologists will be even busier and make more money per procedure.

The theory is that more people will undergo screening with VC. More polyps will be found. Gastroenterologists will now be doing more procedures instead of screening exams., and making more money.
 
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

:laugh:

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.
 
Hey Task- I interviewed at Parkland today- what an amazing program. Anyway, thanks for all your great responses. You did forget to mention one important thing about the heart/cards...Why does the heart exist?...To pump blood to the gut. :) Crypt
 
As a radiologist, I can tell you that we have a good relationship with the GI guys at our hospital. This is unlike the cards guys with whom we tend to have many issues.

Virtual colonoscopy will in the future replace a screening colonoscopy.... you can bet your house on it. Who would prefer to have something stuck up their ass over a simple high resolution non-invasive CT scan?

But, I do not see how this really changes what the GI guys do. In fact, any positive study will be referred to you guys for definitive tissue biopsy and treatment. We do a lot of virtual colonoscopy research at my program and the GI guys are the ones asking for the study! So, I do not think GI docs have anything to worry about.
 
Good info RadRules. I have a couple of questions about virtual colonoscopy. Is the prep the same? Is it air contrast or both air and barium contrast? Thanks, Crypt
 
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Task:

A Good starter text is:
Yamada, Hand Book of Gastroenterology
This is small and digestible. Its the smaller version of the larger 2 volume textbook. However the current version is 5 years old and doesn't really have the newer therapies nor the most current guidelines.

The best journals are:
Gastroenterology (of course)
American Journal of Gastroenterology (the red journal)
Hepatology
Liver Transplantation

As a medical student I read:
GI/Liver Secrets, second edition.
This is a pretty good text, and even contains some esoteric GI stuff. However it really lacks the fundamentals that you need as a medical student.

Some of the societies that I have joined are:
AGA: free for the first year as a trainee (you can aply for this as a resident, and you'll get free registration to DDW New Orleans this year)
ASGE: also free for trainees.
 
Crypt Abscess,

If you have any questions about Parkland, feel free to PM or email me. Good luck on the rest of the trail.
 
I agree that virtual CT will be a very competitive alternative to the screening colonscopy. However, any positive finding will be sent for diagnostic/therapuetic colonscopy to GI.

Another thing, EUS will not replace tissue biopsy. It has it's limitations as well. However it is a very useful tool in the proper circumstance.

Good luck with GI, it's a great field. It's definitely "the" hot subspecialty in medicine these days.
 
There is a great new study just published in the New England Journal (Dec 4, 2003 issue available on-line) on screening virtual colonoscopy which showed sensitivities in the mid 90s which was comparable wot optical colonoscopy. Its a great study done by one of my attendings and has gotten a lot of lay press (he's been on NBC, CBS, CNN, etc). I think this article and its technique will eventually lead to performing screening exams via CT. As mentioned above, this should not hurt GI docs since they can do targeted examinations for polyp removal or biopsy. The waiting list at most places for screening exams is several months the 2 years so removing that burden will be good for patients and the GI docs.

The prep for virtual colonoscopy is the same as real colonoscopy. I believe patients are given PO and PR contrast (not barium). No sedation is needed.
 
Regarding 12/4/03 NEJM on virtual colonoscopy, the study did not used the same previous methods. The study used Barium enema plus high resolution 3 phase CT scan/highly trained academic radiologists.

These are my takes on virtual colonoscopy:
-it's ONLY diagnostic (can not do biopsy...colonoscopy do both)

-still need strong bowel preps as in colonoscopy

-need to insert a rectal tube into a rectum and insufflates air without any sedation (Vt can still be invasive. most patients found this quite surprising..and pt satisfaction not so great as we expected) and this causes abd discomfort (rarely perforation)

-you will get post-procedure constipation or dirrhea if barium enema used

-you get exposed to high dose of radiation

-still expensive (same or more than colonoscopy)--> the current cost effective analysis shows that coonoscopy alone as a screening and therapeutic tool is cost effective (~$35,000/yr life saved) but it's very doubtful that medicare and HMO will ever pay for both procedures (too expensive....and likely not be cost-effective <--although no cost-effect analysis. The cut-off for cost-effective CRC screening is <$35,000 as per USPTF 2002 and UNC.)

In conclusion, I think VT will be a lucrative test for some people at academic centers. I don't think it will ever be a main stream screening test.
 
I disagree about virtual colonoscopy not becoming mainstream. The body imaging fellows at my program have been asked by interviewers at private practice jobs (one in a small town) if they were trained in this and could start a program there. Mostly, its the GI docs with 2 year backlogs asking the radiologists if this will be initiated.

Yes, accurate virtual colonoscopy requires air and barium contrast (only a small amount of barium remains in a double contrast study so no constipation) and can be somewhat uncomfortable. However, the risk of perforation is much lower than colonoscopy (almost zero) and the patient can drive home that day since no sedation is used.

I believe the most effective virtual colonoscopy program would involve a screening VC program with agreement with the GI department to perform endoscopy that day while the patient is prepped for any positive findings. While this may take some work logistically, once in full swing it should run smoothly.

The most important aspect of VC is the prospect of more reluctant patients agreeing to have this very important screening exam. If everyone followed recommendations, advanced colon cancer would be very significantly reduced.
 
Again, I am reiterating what I wrote earlier. To be a main stream screening test, the test has to be:
-cost-effective (in terms of $/yr life saved). According to Univ North Carolina's study and USPTF (US Preventive Task Force), an effective colorectal cancer screening test is $35,000 per year life saved. Colonoscopy as a single CRC screenig test is still cost-effective but the rough estimate of using both VT and optical colonoscopy is not (>$50,000).

-The HMO and government in the end must accept, recommend and pay for the test. The test must be widely accepted in public and and by the major societies publishing the current CRC guidelines. Again, back to the cost-effectiveness of a screening test, HMO and Government would rather pay for one single stop that can do both screening and polypectomy if necessary. The evidence for this? Well, many hospitals/HMO are switching flex sig to a full colonoscopy. If the test is not accepted, the cost will payed by the patients and the doctors will make more money (incentive?)

-I agree that some people will con't to talk about VT for a while (Thanks to one way news media). I worte earlier that VT is/will be a lucrative test for some high class people who can afford to pay it with cold CASH.

-By the way, patient exit surveys show that majority of patients found more discomfort with VT (no sedation) than with optical colonoscopy (with analgesics/sedative)

-Now, talking about very positive things about VT...VT will always have a good slice in the future. There are a few good indications for VT instead of optical colonoscopy. One of the situation is when pt has a known distal obstructing colonic lesion, and the surgeons wants to know if there is any proximal lesion before digging in there. Also, there are currently a big shortage in GI, if VT can take care of those upper class people who can afford to pay CASH for VT, it will relieve the current burden of colorectal cancer screening. Proabably, the best senario is making VT and optical colonoscopy avaialable at the same day/place. This will also relieve the current CRC screening burden.

In the end, there are many more studies, trial errors, people, and money needed before VT to be considerd a main stream. This will not happen for quite some years.

MS IV
going into IM
 
Virtual colonoscopy has already reached a point that is comparable to colonoscopy. The problem is that it is highly dependent on gadgets that are still too expensive. Furthermore, the procedure requires a highly skilled radiologist and is therefore very operator dependent. A recent multi-center study showed the sensitivity of detecting polyps for virtual colonoscopy to be from 90 to 0%. A very unreliable rage indeed but as the technology improves and the procedures are standardized radiologists will be able to do a much faster and cleaner job of screening for colon cancer, better than or at least comparable to what GI doctors are capable of doing now. Anyone who thinks otherwise is in denial. This would surely translate into less pay for GI doctors but let?s keep in mind that the future of medicine is CAPITATION and regualted reimbersement and no one, including the radiologist, is immune from this trend.
 
In a study I read by the radiologist at Mayo show they were having problems detecting lesions that are flat. Also they were having problems to get consistent reading from different radiologists even within the same instutition. Just wondering if there is any radiologist out there can provide with some update?
 
I do not underestimate the future of virtual colonoscopy. VT will always have a role in screening as its' tech improves further.

But it will never be a major screening modality.

VT costs will be out of the patients' pocket until it is widely accepted by public and professional societies. In order for VT to accepted by HMO and the professional socieities:

-the NEJM 12/4/03 study should be reproducible in multiple mass scale studies. As you said, the validitiy and reproducibility of the current and past VT results are low and extremely variable.

-People gotta probe that VT as a screening tool is cost-effective. please see my previous replies on this....Unless radiologists drop the price of virtual colonoscopy far below the regular optical colonoscopy, the screening will not cost-effective (think about cost of the machine, tech, radiologist, time). Remember, the majority of papers and textbooks show that upto 1/3 Americans at 50 or older, have polyps.

-The VT screening was targeted for finding adenomatous polyps greater or equal to 10mm. This is based on the concept that the adenoma to carcinoma sequence takes many years. However, there are many recent papers showing that high grade dysplasia and villous features are also common in smaller polyps. What are you gonna do if your patient ahs a polyp 5mm in diameter. Until you take out the polyp by polypectomy, you will not know the pathology (r/o focal malignancy or high grade dysplastic features), right? With Vt, you may be able to tell the size of "larger polyp" but not the pathology. All the VT papers out there were not as good in detecting small polyps and flat polyps. Also, persons with hyperplastic polyps have ghigher incidence of concomittent precancerous lesions. What do you think? If these become widely accepted VT will not be good unless osmething changes.

-The study was done on healthy, compliant, veteran population (2 Naval MC and Walter Reed MC). Yuo can not generalize and apply the same finding to the rest of the population in the U.S.

-Also, what are you gonna do with the extracolonic findings (lung lesion, ovarian lesion, gallstone, kidney stone, etc) detected on VT in asymptomatic, healthy individuals? Are they good or bad? It is certain that this will raise the screening costs further up. Knowing that there is an abnormality in an asymptomatic patient, you are obligated to do a further investigation or treatment. One thing for sure is that these findings will not make the VT a more cost-effective screening tool. These will rather increase the total cost of the mass screening. The radiologists have tried to push the CT-scan for screening lung cancer in population but the whole thing dropped when it became obvious that it was not cost-effective.


MSIV
going into IM
 
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