Dr Burr Loew, Private Practice
Fellowship provided a strong focus on clinical training. I was challenged by and learned a great deal from complex patients seeking third and fourth opinions in gastroenterology (if two or three smart gastroenterologists had not been able to fix them, what chance did I have?). Even 60–90 min for a new patient encounter sometimes seemed insufficient for an unseasoned gastrointestinal (GI) fellow. Sifting through complex medical history and piecing together extensive prior GI evaluations could be tedious and time consuming. Private practice routinely involves more mundane and less complex “bread and butter” gastroenterology where a 20–30 min initial office visit is enough to understand the problem and make an appropriate diagnostic and management decision. Typically, the first stages of GI work-up begin after an initial office consult, as opposed to being a latecomer to their GI evaluation as was often the case in fellowship. Following a basic GI evaluation, many patients see improvement with a proton pump inhibitor (PPI), a low-fermentable oligo-di-monosaccharide and polyols diet, a low-dose tricyclic antidepressant, or even simple reassurance. Occasionally, they do not require follow-up. Our office places status phone calls 2–4 weeks after an office visit to make further adjustments or fine-tune the management plan. This frequently suffices to determine whether further follow-up, additional testing, alternate therapeutic agents, or simply a “call if symptoms return or worsen” is needed. Although only a small fraction of the 25–30 outpatient visits per week involve degrees of complexity encountered during fellowship, the training experience laid the groundwork for my comfort with the variation and complexity within the GI spectrum.
ADAPTING TO YOUR RESOURCES
During fellowship, virtually all types of GI testing were readily available, including most of the gold standards. My work-up algorithm tended to mirror GI society guidelines. Once in private practice, my approach quickly evolved. Our practice is located in a busy suburban area but services a large rural community. Gold-standard tests such as esophageal manometry, pH probes, anorectal manometry, and, until recently, endoscopic ultrasound were only available 60 or more miles away. I quickly discovered that many patients, for lack of money or time, were reluctant to proceed with such diagnostic endeavors. Could a relatively certain diagnosis of diffuse esophageal spasm or achalasia be made with endoscopic and barium swallow findings? What about the diagnosis of functional heartburn in a young woman with likely visceral hypersensitivity, a normal esophagogastroduodenoscopy, and no improvement on a PPI? Or the patient with presumed pelvic floor dyssynergia based on clinical history with or without a suggestive Sitz-marker study? I have found that in many situations the answer seems to be yes. Although the lack of gold-standard testing was initially disconcerting, in certain situations where suspicion for ominous pathology is low, therapeutic trials now seem reasonable. We certainly still send patients for additional testing if they fail treatment, if further testing could reasonably impact treatment, and if they are willing. However, I have developed a clinical sense or gestalt in these situations.
ADVANCED TRAINING AND LENGTH OF FELLOWSHIP
As fellowship training evolves and more fourth-year advanced fellowship programs are added, training for those not seeking a fourth year has changed. During my second year of training, I was only able to perform 40–50 endoscopic retrograde cholangiopancreatographies (ERCPs) and a handful of endoscopic ultrasound cases because most were saved for the advanced fellows. Clearly, this is well below the accepted guidelines for both credentialing and to gain confidence performing these procedures. Instead of additional procedure training, much of my third year was dedicated to completing academic interests. The final 6 months seemed less useful, as I had already completed core training and demonstrated endoscopic proficiency. For those physicians' going into private practice who do not plan to perform large numbers of advanced procedures, GI fellowship could be reduced 2 years with little negative impact on the quality and completeness of training. Our group has seen this paradigm shift, as only three of our six physicians perform ERCP, and only one performs endoscopic ultrasound.
THE IMPORTANCE OF RELATIONSHIPS
No matter the degree of autonomy provided during fellowship, the ultimate responsibility that accompanies being an attending physicianis a daunting adjustment. Although your clinical decision making is no longer consistently reviewed, older colleagues can be especially helpful in navigating the logistics of practice and discussing case histories, test results, and management approaches. The network of relationships formed with contemporaries and experts in the field serve as indispensable resources post fellowship. Running a complicated case by a former attending physician is an invaluable resource, sometimes if only for reassurance. As the years after fellowship accumulate, my comfort level grows and I find myself doing this less often.
Dr Matthew Rockacy, Academic Medicine
ADVANCED VS. GENERAL GI PATIENTS
Overall, I feel that my fellowship training was well rounded, with excellent endoscopic as well as clinical training. I experienced more than adequate exposure to general GI problems, as well as pancreaticobiliary, esophageal, liver diseases, and inflammatory bowel disease. Given my focus on advanced endoscopy and pancreaticobiliary diseases, I received less exposure to functional and motility disorders, which is ironic now that many of my patients in practice have functional problems. Fellowship training was heavily focused on inpatient medicine, although as an attending physician, the majority of my practice is in the outpatient setting.
THE BUSINESS SIDE OF MEDICINE
My transition to full-time attending status was eased during my fourth year of fellowship training, during which I performed unsupervised general GI procedures 1 day per week and covered week-long inpatient service throughout the year. Despite this excellent training, the 1 year (or more) of being an attending physician has a steep learning curve endoscopically, clinically, and beyond. You are now the primary decision maker and there is no longer an attending physician at your side during procedures. There is increased responsibility; the outpatient world does not stop while you are covering the inpatient service. Phone calls must be made, letters must be dictated, pathology, imaging and laboratories must be reviewed, and decisions must be made in a timely manner. Then there is the “business side of medicine,” with billing, coding, and dealing with insurance companies. The business and financial sides of medicine are infrequently addressed in fellowship, but fortunately the basics are quickly learned.
THE IMPORTANCE OF RELATIONSHIPS
Beyond the gastroenterology training, an important part of fellowship is the relationships that one makes, as these will be important lifelong contacts. I was fortunate, as hopefully the majority of GI fellows are, in establishing a network of relationships with colleagues, co-fellows, and mentors during my 4 years of fellowship. These relationships are an indispensable resource, particularly during the first few years of post fellowship. Being able to review challenging cases, discuss treatment options, or simply just talk and reminisce is a true respite during stressful times.