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Lifestyle of a GI doc/resident

Discussion in 'Gastroenterology' started by Stillwell, Aug 10, 2002.

  1. Stillwell

    Stillwell Member
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    Hi,

    I was just wondering what life was like as a GI fellow (hours, call, etc), how hard it is to get a GI fellowship, and what the life of a GI doc is like:
    - Is there a lot of night call for GI bleeds, etc?
    - Are the jobs saturated in most cities, forcing GI docs to go to rural areas?
    - Is the malpractice insurance high?
    - Is your salary largely dependent on the number of procedures you do? It seems they have the potential for a lot of money, but some job ads i see offer starting $180K/yr.
    - What is the future of Gastroenterology? Is there any possibility of other fields moving in on their procedures (radiologists doing ERCPs, surgeons/Internists doing scopes, etc).

    Thanks for any info -
     
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  3. tulip

    tulip Junior Member
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    Good questions. The only thing I am pretty sure of is that the job market, and specifically in the state of NY, will be pretty good for the next few years. I have heard that the lifestyle of a fellow is rigorous but not as bad as cardiology. I wish we could hear from some fellows on this board...
     
  4. tulip

    tulip Junior Member
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    Good questions. The only thing I am pretty sure of is that the job market, and specifically in the state of NY, will be pretty good for the next few years. I have heard that the lifestyle of a fellow is rigorous but not as bad as cardiology. I wish we could hear from some fellows on this board...
     
  5. task

    task Senior Member
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    GI has emerged as the most competitive IM subspecialty, a result of high demand, high reimbursement, comparatively better lifestyle than Cards and GI fellowship programs keeping the number of fellowship spots low and stable. There are something close to 800 Cards spots and 250-300 GI spots, so the truth is in the numbers.

    Lifestyle during fellowship will probably vary from program to program. Most GI procedures are elective, with busy night call dependent on how many bleeders show up in a given night. Remember that 80% of bleeds resolve on their own, so you're definitely not up as much at night as you would be in Cards.
    Otherwise, the bulk of your day while you are at work is busy with consults and endoscopy.

    Historically, GI has been very protective of its procedures. For example, while there are surgeons who do ERCP, ERCP is a technically demanding procedure that requires a lot of experience, and is not something one can be proficient at just doing it every so often. Complicated biliary cases can take 3-4 hours or longer. For these reasons, there aren't many surgeons who do ERCP. I actually think the # of ERCPs done in the future will decrease, but not to the detriment of GI docs. Instead, the new wonder-technology that is EUS will keep GIs busy. The clinical indications for EUS for both diagnostic and therapeutic purposes is expannding every day. EUS is extremely challenging both from a diagnostic and technical standpoint, and this will remain well within the realm of GI as well. Capsule endoscopy is being pioneered by GIs as well, and from what I've seen they have no plans to relinquish it either.

    As for screening virtual endoscopy, the general opinion from most GI fellows and faculty I've spoken to is "let the Radiologists have it." From their standpoint, there is such a backlog for screening procedures and they are already so overloaded with endoscopies for biopsy that any efforts to alleviate the screening backlog would be welcome. Frankly speaking, they don't need the screening business. Interesting

    Lifestyle after fellowship is gonna depend on practice type and size. But like with anything else, I think you can make your lifestyle what you want.
     
  6. Stillwell

    Stillwell Member
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    Thanks, that's good info. I'm not very familiar with EUS. Is it endoscopic guided ultrasound like used in TEE's? I didn't know that would be an exclusive GI thing if so.
    About the capsule endoscopy, I have read about this before. It seems to me it will hurt GI docs because it's less invasive, the patient isn't made uncomfortable due to the scope, it's cheaper, insurance companies won't have to pay for the lab use, the anesthetics, the nurse to assist, etc. I know it's indicated mainly for GI bleeds right now, but I figure it's only time before it is used for all things GI related. Of course, after the capsule relays the info the GI doc may have to go in and biopsy, but it seems it will still cut down on the number of scopes (and compensation) for them. Also I saw them talking about these capsules on a family practice website, and I wonder if soon you can go to your PCP, get the pill, have him/her read the results, then send the patient to a GI doc to get biopsied.
    Maybe I'm thinking too much, but it seems it could happen in a few years once the bugs are worked out. -
     
  7. task

    task Senior Member
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    Yep, EUS is Endoscopic Ultrasound. The images generated by EUS are pretty amazing and don't require the use of fluoro. EUS can be used to guide both diagnostic and therapeutic procedures like biopsy, psudocyst drainage, and even stent placement. I've only seen a few cases, but it does require proficiency with side viewing endoscopes (pretty challenging) and interpretation of the images takes A LOT of experience. Many in GI feel this will be as revolutionary as ERCP is, if not more so.

    With regards to capsule endoscopy, the real utility will be for lesions beyond the reach of an endoscope, for lesions farther along the small bowel. GIs are pioneering the use of capsule endoscopes. The problem is the amount of time it takes to review the images generated by a capsule endoscope -- this won't change as the technology advances. Who will take the time to sit and read the images generated is a topic of some debate, but right now GIs seem to have the area well in their turf. The issue will be what to do with lesions seen beyond the endoscope in the upper GI tract. Do they need to be referred on for some from of surgical biospsy? Some faculty in my department seem to believe that visualizing the lesion will be sufficient in most cases, and only if the worry for malignancy is extremely high (past the duodenum is pretty rare anyway) would any tissue be warranted.

    I suppose PCPs could do virtual endoscopies, but this may come down to a matter of reimbursement. For example, residents coming out of my Medicine program are expert at placement of central lines, chest tubes, S-G catheters, etc. But let's say one of these residents goes into private practice as a general Internist. Is it worth his/her time or risk to do one of these procedures. Absolutely not. First of all, a general Internist's reimbursement schedule is optimized for the delivery of outpatient care. A half hour seeing 2 or 3 patients pays far better than a half hour putting in a subclavian, let alone extra time and effort spent to place a chest tube if he/she drops a lung. Why even pay the malpractice to cover doing invasive procedures if you don't get reimbursed well for them? So the Internist calls the Critical Care, Cardiologist or Surgeon to place the line. They have the malpractice coverage for the procedure, and they can actually bill at a higher rate of reimbursement for the line than the Internist can. You can see how the logic would follow for capsule endoscopy -- time spent administering and interpreting the images would not pay as much for a general Internist compared to the GI doc. The PCP's time is better spent (from a fiscal standpoint) seeing patients.

    Advances in minimally invasive screening will be beneficial for GIs in many ways. Most people don't realize the absolute overload of screening procedures GI currently faces. Any technologies which will decrease the procedural screening load and allow GIs to focus on going after things to biopsy or treat will eventually balance out to more, not less, overall for GIs in terms of procedures and overall compensation. It pays more to acutally do something like biopsy or treat than a screening, so from a resource allocation standpoint, GIs will benefit as well.

    Look at it this way -- many folks don't go for screening colonoscopy because of the fear and discomfort of have the scope put in your butt. Send all these people for a minimally invasive screen (who wouldn't have gone for an endoscopy in the first place), tell them there's a polyp there, and you bet they'll be in the GI lab sooner than you can blink asking for a colonscopy with biopsy.
     
  8. Voxel

    Moderator Emeritus 7+ Year Member

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    Hey, good to hear that you guys are willing to let radiologists do screening virtual colonoscopies without that much of an uproar. I understand you guys are so backed up as it seems to take a while to get patients (non-emergent) scoped. However given the current shortage of radiologist, I'm not sure we could handle the screening case load. I guess we might be persuaded somewhat if the reimbursement was similiar to a real colonoscopy. :) GI is a great field, if I was doing categorical medicine, GI is what I'd be shooting for.
     
  9. Burton

    Burton Member
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    Hi guys,

    I'm currently an MS3 and I've been seriously considering GI. I'd like some advice on how to best approach making myself into a good candidate. Should I do a GI away rotation where I want to go? Or should I concentrate on just getting into IM and worry about GI later?

    What else is good for GI, e.g. do they especially like research experience?

    Any words of wisdom are welcome.

    Thanks,
    Michael Burton
    Texas Tech SOM
    Class of '04
     
  10. task

    task Senior Member
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    Michael,

    I'd focus first on getting into the best IM residency you can. If you can get involved or on board with some GI related research now that could develop into published articles or abstracts, by all means do so. That will help you for IM as well as GI.

    A GI away rotation now at a place you'd like to go for IM is a good idea, but remember, as with all away rotations, be prepared to put on your best show. First impressions are key.

    Email me with more questions as you have them.
     
  11. Airborne

    Airborne Senior Member
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    All:

    There have been several threads on SDN regarding fast-tracking into GI - I was wondering if anyone has gone through this or knows of anyone who has?

    I've perused the previous threads and am aware of the time requirements (ie 2 years in IM, 2 years research, 2-3 yrs GI training), but what I am still unclear of is how many people actually do this and how difficult otaining such a position would be?

    Thanks,

    Airborne
     
  12. task

    task Senior Member
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    I've posted on this topic a few times, so I'll keep it brief.

    Fast-tracking outside of non-competitive specialties like ID, Renal, Heme-Onc, Endocrine, etc. is virtually unheard of. The only way to justify fast-tracking in any field is to demonstrate that you're headed down the academic medicine route and that because you will be in a lab for 2-3 years in fellowship, you should get to leave Medicine residency a year early. So you don't save any time anyway.
     
  13. Burton

    Burton Member
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    Thanks for the advice, Task.

    I was thinking about doing some research or something with the GI dept. I was wondering if many people have had experience back in med school with getting published or getting involved with clinical research? Is there time? What's the most realistic thing you can do?

    Thanks,
    Michael
     
  14. rajvosa

    rajvosa Senior Member
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    How would you rank IM programs in NYC?
     

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