GI Hours/lifestyle

[IM2GI]

I respectfully disagree. To be an all rounded highly skilled therapeutic endoscopist 250 is needed based on innumerable conversations I had with leaders in the field, nationally and internationally and based on my own experience. To be a non-lethal ercpologist 150 is the minimum. Clearly these are averages and some exceptionally talented people may need less but the number of devastating complications I have seen and dealt with attests to the fact that many are doing procedures that they shouldnt be doing. Similarly, I have seen my share of missed cancers from non focused endoscopists who just "picked eus up" to do simple biopsies.
150 is the consensus number for minimal simple ercp basic competency and some argue that 2 to 3 native papillas per week should be within that minimum. Unfortunately the literature on this is weak and all over the map.

As you point out, there is a relatively fixed number of ERCPs done annually at a given center. New grads already are having a hard time finding jobs:

Advanced endoscopy fellowship training in the United States: recent trends in American Society for Gastrointestinal Endoscopy advanced endoscopy fellowship match, trainee experience, and postfellowship employment

The American Society for Gastrointestinal Endoscopy (ASGE) advanced endoscopy fellowship (AEF) match offers a structured application process for AEF training in the United States. Our aim was to describe recent trends in AEF match, trainee experience, and postfellowship employment.

www.giejournal.org

"75% of trainees participated in >300 ERCPs and 64.1% in >300 EUS cases. Seventy percent of trainees reported that advanced endoscopic procedures comprised ≤50% of their procedure volume in their first job, and 71.9% believed it was not easy to find a job after fellowship; however, 97% believed they would make the same decision to pursue AEF training again."

The number of ERCPs done will not continue to scale with the number of advanced fellows we are training. This does not even factor in the community programs that will certify you in ERCP in 3 years, which is questionable.

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees

Minimum EUS and ERCP volumes that should be offered per trainee in “high quality” advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an “average” advanced ...

www.ncbi.nlm.nih.gov

The consensus is you can go from zero to 300 cases and become competent at "grade 2" difficult ERCP. Saying then you need to do 300 a year in perpetuity to maintain those skills is a stretch.

I certainly agree that those out there doing 20-30 cases annually are probably dangerous. I think the question becomes once you hit a 75/year or some other arbitrary number, are you significantly different than someone doing 250/year?

Your point is that basically, health systems should employee 1 or 2 dedicated advanced endoscopist who do nothing but advanced cases all day. This is an ivory tower approach that is not practical in many systems and communities. I know many advanced providers that also don't want that lifestyle. You mention you are single and without a family, and I suspect your approach will change as your priorities in life do as well. You should come back and read this thread in 10 years.

Just saying that I think you should be respectful and not demeaning of your colleagues doing 80-120 a year and doing a good job. You might be one of those guys/gals during your career.

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[adagio]

First, I apologize if what I said struck you as demeaning. I do see where you are coming from. There are lots of nice doctors who try to do a good job. This was not meant to bash them in favor of an elitist or ivory tower approach. I simply was sharing what I learned from extensive conversations and discussions on this very topic with mentors and other high-level colleagues in the field. My philosophy about this topic (which seems to be sensitive, and If you are a practicing colleague that feels slighted, I am again very sorry because this was not my intention) stems from personal observations and the opinion of experts far more knowledgable than myself.
While you mention some of your therapeutic colleagues who do not want this lifestyle, I will tell you that many mentors and colleagues sacrificed and accepted this lifestyle to be on top of their game and be the best of the best. I hope that one day I can become one of them.
To add more confusion, most studies on this topic will focus on the "center" volume, not the individual volume.