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  • So you want to be a gastroenterologist.

  • You like the idea of poop, the digestive tract, and more poop.

  • Let's debunk the public perception myths, and give it to you straight.

  • This is the reality of gastroenterology.

  • Dr. Jubbal, MedSchoolInsiders.com.

  • Welcome to our next installment in So You Want to Be.

  • In this series, we highlight a specific specialty within medicine, such as gastroenterology,

  • and help you decide if it's a good fit for you.

  • You can find the other specialties on our So You Want to Be playlist.

  • If you want to vote in upcoming polls to decide what future specialties we cover, make sure

  • you are subscribed.

  • If you'd like to see what being a gastroenterologist looks like, check out my second channel, Kevin

  • Jubbal, M.D., where we'll be covering a day in the life of a gastroenterologist soon.

  • Gastroenterology is the specialty within medicine focusing on the gastrointestinal system, including

  • everything from the mouth to anus along the alimentary canal.

  • It's the only field that's truly mouth to anus, covering not only the entire gastrointestinal

  • tract, but also the pancreas and liver.

  • Conditions you'll manage include inflammatory bowel disease, or IBD, not to be confused

  • with irritable bowel syndrome, or IBS, which you'll also treat.

  • Colon cancer, which, excluding skin cancer, is the third most common form of cancer among

  • men and women in the United States, will also fall under your preventative screening and

  • management.

  • Gastroenterologists deal with dysphagia, meaning trouble swallowing, and anything relating

  • to nutrition.

  • After all, the gut is where we absorb nutrients and water.

  • Liver diseases, such as liver cancer, cirrhoses, and hereditary pathologies such as hemochromatosis

  • or alpha-1 trypsin deficiency fall under GI care, as do pancreatic diseases such as pancreatitis

  • or pancreatic cancers.

  • Ultimately, gastroenterology is a subspecialty of internal medicine, and having a strong

  • foundation in internal medicine is essential to be an effective GI doctor.

  • After all, many of the GI conditions and pathologies you'll encounter are closely involved with

  • other parts of the body.

  • For example, the liver is intimately connected with the adrenal system and kidneys.

  • The brain-gut is another intimate association that can influence your patient's symptoms

  • and disease course.

  • Gastroenterology is a unique subspecialty of internal medicine, as it combines a high

  • degree of clinical continuity and longitudinal care with procedural medicine, something that

  • few other specialties providecardiology being another example.

  • While not a surgical subspecialty, you are working with your hands plenty.

  • Gastroenterologists perform endoscopies, colonoscopies, ERCP's, and biopsy of virtually any abdominal

  • organ via endoscopic ultrasound.

  • Moreover, it is now quite common to have many procedures, previously only addressed by surgeons,

  • now performed endoscopically as it is often less invasive for sicker patients - these

  • might include drainage of abscesses, placement of a luminal stent, or a nissen fundoplication.

  • You'll work with either pediatric or adult patients, and you'll be dealing with both

  • acute and chronic processes.

  • Those acute processes will be anything but boring.

  • Bleeding gastric ulcers are high acuity and can be life threatening, and foreign body

  • removals, such as toy cars or phallic shaped objects in someone's behind that they "accidentally

  • slipped on" is a common occurrence.

  • From the top end, poorly chewed meat, dentures, chicken bones, and even silverware will require

  • your expertise in removing safely.

  • There are a few ways of categorizing gastroenterology.

  • As an academic gastroenterologist, you'll be focusing on teaching students and GI fellows,

  • in addition to the academic side of medicine.

  • In academia, you typically see more variety in pathology, unique cases, and rare hereditary

  • diseases.

  • As a community gastroenterologist, working in a smaller institution, you'll be dealing

  • with more bread and butter cases that tend to be less complicated or unique.

  • If you're at a county hospital, where patients often don't seek medical help until much later,

  • you might see more rare, advanced pathophysiology and presentations.

  • Private practice is the least common practice setting for a gastroenterologist, and usually

  • only occurs in smaller towns.

  • It's more difficult to manage because there are multiple moving parts in a GI practice,

  • including both acute and chronic as well as procedural and non-procedural.

  • Coordinating staff, clinic, and most importantly patient safety, such as cleaning scopes, proper

  • sedation, and having state of the art equipment, makes private practice increasingly cumbersome.

  • As an outpatient gastroenterologist, you'll have the more standard 9 to 5 or 8 to 4 working

  • hours and a predictable schedule.

  • This offers flexibility with your lifestyle, including better hours, and a high degree

  • of clinic time and procedures, primarily in diagnostic screenings, such as a colon cancer

  • screening colonoscopy.

  • You'll generally spend 3 or 3 and a half days doing procedures each week, and 1 and a half

  • to 2 days in clinic.

  • The majority of your work will be outpatient in nature, but a few nights per month you'll

  • be on call with the local hospital or academic setting for emergencies.

  • As an inpatient gastroenterologist, you're likely to be working in academia.

  • Again, this translates to teaching medical students, residents, and fellows, and also

  • seeing more advanced pathologies.

  • You'll be busier than your outpatient colleagues, and patients will be sicker.

  • It's more rigorous, but for many the rewards pay offprimarily in teaching and involvement

  • with more intricate procedures, such as ERCP in dealing with the liver and pancreas.

  • In terms of schedule as a GI in academia, you can expect typically 9 to 6 pm depending

  • on inpatient rounds with some time on call at night each month.

  • If you are a GI hospitalist, you can expect one week on and one week off, like an internal

  • medicine inpatient hospitalist.

  • Gastroenterology is a fascinating field.

  • After I was diagnosed with inflammatory bowel disease over 10 years ago, I was actually

  • inspired to pursue pediatric gastroenterology so that I could help children with similar

  • digestive disease processes.

  • I was drawn to the procedural elements and found nutrition and digestion fascinating,

  • but I ended up pursuing plastic surgery.

  • That's another story told on my personal channel.

  • Many people think that because of the colonoscopies and other procedures within GI, it's a field

  • that's hard on your nose.

  • The truth is, it rarely smells bad because patients are generally prepped beforehand,

  • meaning their colons are cleaned with laxatives to improve visualizing the colon walls.

  • While GI is technically mouth to anus, you'll find in practice that it more practically

  • begins at the upper esophageal sphincter.

  • Above that, it's primarily ENT, also known as otolaryngology, although there is some

  • overlap between the two.

  • And yes, digital rectal exams are important, and if you're a medical student or resident

  • don't shy away from them.

  • And for the rest of you, make sure you're comfortable with poop if you're considering

  • GI.

  • To become a gastroenterologist, you first complete 4 years of medical school, then 3

  • years of internal medicine residency, and then 3 years of gastroenterology fellowship.

  • That's a total of 6 years of postgraduate training after medical school.

  • Many gastroenterologists also pursue an additional 1 or 2 year fellowship to further subspecialize.

  • Gastroenterology is one of the most competitive internal medicine fellowships, duking it out

  • with cardiology.

  • They do consider all three USMLE scores, including Step 1, Step 2CK, and Step 3 in assessing

  • your application.

  • Research is also highlighted, with the average matriculant having 11 research items, compared

  • to 9 for cardiology.

  • This isn't so much a rite of passage, but rather highlighted because gastroenterology

  • is a rapidly changing and evolving field.

  • Hot topics in gastroenterology right now are related to new endoscopic surgical techniques

  • such as POEM, or Peroral Endoscopic Myotomy, an endoscopic procedure used to treat swallowing

  • disorders, most commonly for Achalasia.

  • Another hot topic is the gut microbiome as it relates to various aspects of health including

  • the gut.

  • There is also attention focused on developing oral medications rather than intravenous for

  • ease of administration for patients, especially for those with inflammatory bowel disease.

  • If pediatric gastroenterology is your goal, then you'd first complete three years of

  • pediatrics residency rather than internal medicine residency.

  • After that, you would complete 3 years of pediatric gastroenterology fellowship.

  • If you're interested in doing surgery on the digestive tract, you want to look to general

  • surgery and its subspecialties, such as colorectal or hepatobiliary surgery.

  • That's a separate residency training process, whereby you match into general surgery first

  • and complete the relevant fellowship after.

  • As for the medical students who typically go for gastroenterology, they're usually the

  • ones who enjoy a fast paced specialty, are efficient, yet are also laid back and can

  • handle the sometimes high acuity and stressful situations.

  • They're adaptable and versatile, being able to turn on and quickly lock in for an acute

  • bleed, but also able to slow down for clinic.

  • Most of the gastroenterology fellowships are 1 year in duration, although some programs

  • are 2 years, particularly if they have a heavier focus on research.

  • Note that with any of these fellowships, you'll still be treating general gastroenterology

  • conditions and performing screening colonoscopies in varying amounts.

  • Interventional and advanced endoscopy focuses on endoscopic procedures, such as endoscopic

  • retrograde cholangiopancreatography, or ERCP, to visualize the gallbladder, biliary system,

  • pancreas, and liver.

  • You'll also be trained in endoscopic ultrasound, which is similar to endoscopy, but rather

  • than a camera at the end, you'll have an ultrasound probe.

  • Ultrasound is commonly done from the outside of the body, but endoscopic ultrasound offers

  • internal imaging that's highly accurate, and is used to diagnose cancer, take biopsies,

  • or place enteral stents.

  • Advanced endoscopists do a great deal of stenting when cancers obstruct the GI passages, whether

  • in the esophagus, stomach, small intestine, or colon.

  • In these instances, your interventions are more therapeutic or palliative, rather than

  • curative.

  • It's a highly rewarding subspecialty, but it comes with longer hours and is often inpatient

  • in nature.

  • You'll also be wearing lead aprons for long periods of time for frequent use of x-rays,

  • which can be tiresome, particularly when also maneuvering the scope.

  • Inflammatory bowel disease is an autoimmune condition, consisting of two types: Crohn's

  • disease and ulcerative colitis.

  • With an autoimmune disease, the body is attacking itself, and these are the specialists in managing

  • the heavy hitting and sometimes dangerous immunosuppressive agents that get this disease

  • under control.

  • It's a rapidly evolving field, taking a closer look at how the gut microbiome influences

  • these conditions.

  • You'll also be dealing with awesome patients like me.

  • In terms of lifestyle, hours are the more predictable and typical 9 to 5 in nature.

  • Hepatology and transplant hepatology are the experts on the liver, dealing with liver cirrhosis,

  • autoimmune diseases of the liver, hereditary diseases, and liver failure.

  • While the transplant surgeon will be doing the actual harvesting and surgery, you'll

  • be evaluating the patient for liver transplant candidacy and will provide pre-op and post-op

  • care.

  • Often times, this includes stabilizing and improving a patient's health from first presentation

  • such that they are realistic liver transplant candidates.

  • This requires careful attention and nuance to medication management and peri and post

  • operative care.

  • Motility is the least common of GI fellowships, dealing with peristalsis of the gastrointestinal

  • tract, meaning the wavelike motion that propels food down the alimentary canal.

  • These coordinated contractions push stomach contents into the small intestine, or help

  • the colon and rectum move feces prior to having a bowel movement.

  • Peristalsis is reliant on the nervous system, endocrine system, and balance between sympathetic

  • and parasympathetic systems.

  • Motility experts are often working with various systemic conditions that impair motility,

  • such as neurologic diseases or scleroderma, an autoimmune connective tissue disease that

  • causes hardening of the skin and other tissues.

  • There's a lot to love about gastroenterology.

  • It uniquely offers a good breadth of medical knowledge applied in both the acute and chronic

  • settings.

  • If you enjoy procedures but don't quite want to do surgery, consider this specialty.

  • If you're into exciting high acuity situations, there's plenty of GI emergencies through acute

  • bleeds and foreign body ingestion.

  • On the other hand, you also enjoy longitudinal care and building relationships with your

  • patients, as many GI diseases are chronic in nature.

  • Mastery is inherently rewarding, and my gastroenterologist friend says it's a very easy specialty to

  • master, assuming you have a strong foundation in internal medicine first.

  • In terms of compensation, it's usually in the top 6 specialties, most recently at $419,000

  • per year, which makes sense given its procedural nature.

  • You have flexibility with your lifestyle, and are able to have 9 to 5 hours while also

  • making a very comfortable living.

  • There's currently a widespread shortage of gastroenterologists in many cities, and therefore

  • you'll be in high demand, giving you leverage in having the type of practice you want.

  • While GI is an amazing specialty, it's not for everyone.

  • If you are disgusted by the idea of feces, look elsewhere.

  • It's not a constant reality you'll be facing every minute of the day, but you'll be seeing

  • at least a little bit on a daily basis.

  • It can be a fast paced field, and you should be comfortable being able to jump around from

  • clinic to rushing to the ED for an acute GI bleed, and then going to the procedure suite

  • to do your scopes for the day.

  • If you prefer a slow paced specialty, this may not be a good fit.

  • The specialty deals with a high number of chronic diseases, and these patients often

  • require more patience.

  • You are often unable to quickly fix and cure someone of their ailmentif that's what

  • you're looking for, then surgery would be better suited for you.

  • And lastly, I'll touch on my own personal experience.

  • When I was pursuing GI, I spent a great deal of time in the procedure suite, watching dozens

  • of upper and lower endoscopies.

  • I knew that I wanted to do something procedural, but the procedural variety is limited in something

  • like GI, and doesn't compare to surgery in terms of complexity, nuance, and technical

  • challenge.

  • That's not to take anything away from GI.

  • It's simply a nature of the different approachesin surgery, you're completely hands on,

  • touching, cutting, suturing various layers of tissue.

  • In comparison, with gastroenterology you're always separated to a larger degree, as the

  • scope or other tools place you much further from the action.

  • How can you know if gastroenterology is the right field for you?

  • If you're a fun, friendly, laid back person that enjoys the benefits of a balanced lifestyle,

  • flexibility with your practice type or location, while also making a good living, gastroenterology

  • might be a good fit for you.

  • Gastroenterologists are often outgoing and friendly, as they're constantly interacting

  • with others, both patients and colleagues in other specialties.

  • It's a very procedural specialty, so if you're comfortable with that and not terrified of

  • poop, you may have found your match.

  • Big shout out to Dr. Jonathan Kung, board