Being a gastroenterologist has been a tremendous blessing. I love going to work every day. Fortunately for me, I had amazing mentors in my fellowship and I think I was better prepared than most fellows for clinical practice. It served me well to have attendings who were intentional about teaching me clinical and non-clinical skills throughout my fellowship. However, there are always some surprises once you get out of training. Here are five things I wish I knew prior to starting clinical practice.
1. I wish I knew that control of the endoscopy suite matters.
My first job after fellowship was at a small hospital with an incredibly awkward organizational structure and where I was the only gastroenterologist on staff. My clinic (space, staff, supplies) belonged to the Department of Medicine, but the endoscopy suite, including space, staff, equipment, and supplies, belonged to the OR. Because I belonged to the Department of Medicine, I had no actual control over the activities of the endoscopy suite. It was incredibly frustrating having responsibility for the endoscopy suite while simultaneously lacking decision-making authority. If you’re looking at a practice where this is the case, keep looking!
2. I wish I knew that half of my patients would have IBS.
Irritable bowel syndrome (IBS) is the bane of my existence, and I suspect many gastroenterologists feel the same way. As I’ve written previously, I think it’s important to love taking care of IBS. You can’t avoid it, and you can make a profound impact on someone’s life. I actually love my IBS patients, and I genuinely enjoy caring for them, but I know that not everyone does. That said, you will see a lot of IBS patients in practice. It’s a tricky diagnosis and many people don’t manage it well. Here are some common errors I see made with respect to IBS, and I recommend working hard to avoid them.
Error #1: Never diagnosing a patient as having IBS. I see many physicians, particularly in academic referral centers, who don’t make this diagnosis often enough. If you reasonably rule out all of the structural causes of abdominal pain, IBS is all that’s left! Don’t waste a lot of effort looking for rare diagnoses like acute intermittent porphyria. And, don’t just send the patient back to the referring doctor with a note that says, “GI workup negative, no definite source found, return to referring physician for further care.” Call a spade a spade!
Error #2: Making the diagnosis without a proper workup. Some physicians see patients with bad abdominal pain and anxiety and label them as having IBS without excluding structural pathology. Just because they have IBS doesn’t mean they don’t have celiac disease or colon cancer. Do the proper workup! Like I tell my students, “The question is never whether the patient has IBS. You already know they have IBS. The question is whether they have a second diagnosis you need to manage also.”
Error #3: “Turfing” these patients back to primary care physicians. Your referring doctors want you to help them manage their difficult IBS patients. If you don’t take care of their difficult IBS patients, they may stop sending you their colonoscopy screening cases. As a solo gastroenterologist in a small rural hospital, I can’t afford to load my clinic with as many IBS patients as possible, or I’d never take care of Crohn’s disease and cirrhosis patients. If you’re in my situation, you can’t afford it either — and even if you’re in a large group practice, you can and should treat challenging IBS patients.
Error #4: Not believing in the use of SSRIs to treat IBS. Using “antidepressants” isn’t a cop-out in IBS. I know some gastroenterologists don’t believe in using SSRIs, but I think they’re wrong. SSRIs are not the right choice for every patient, and they definitely don’t work for everyone, but I’ve had a lot of success with them! Further, the biochemistry is clear: IBS has a serotonin-mediated origin, and SSRIs may serve your patients well.
3. I wish I knew that other specialists want to do colonoscopies.
Colonoscopies are the best option for colon cancer screening. These procedures pay well, so other people want to do them. I’ve had both primary care physicians and surgeons ask me my thoughts about non-GIs doing these procedures. My general answer is, “It’s a bad idea.” If you don’t have a lot of experience doing colonoscopies, then you’ll run into problems. I can’t even count the number of times a non-GI endoscopist has called me in to save them on a procedure they were struggling with. That’s not to disparage these physicians — it’s not a lack of effort, it’s a lack of experience and training. Also, gastroenterologists do not get paid to take extra time to help non-GI docs with the procedure. You’re assuming risk by stepping into the procedure, and you’re getting no reward. In a situation like mine, that’s fine. As a general business model, however, it’s not going to work.
4. I wish I knew that advanced-level providers make you a lot more productive.
In both of my previous two jobs, I had a nurse practitioner working with me. In both cases, having an NP on board dramatically improved my productivity. With an NP or a PA helping you in the clinic or at the hospital, you can be in the endoscopy suite more, which pays better. Your work relative value units will go way up if you are able to spend a greater percentage of your time in the endoscopy suite. You also expand your clinic’s capacity to see patients by having another provider in the clinic. I see a lot of angst from physicians about “NPs and PAs taking over our jobs.” I think physicians need to simmer down, especially gastroenterologists. I love working with our NPs and PAs! They make my job easier and more productive. They also tend to not have a chip on their shoulder, which is more than can be said for a lot of physicians.
5. I wish I knew how much I’d need to invest in equipment expertise.
You need to be knowledgeable about all of the equipment, especially the high-level disinfection (HLD) system. If you’re ever going to have a problem as a gastroenterologist, it’s going to be with your equipment. The HLD system is an especially big issue, and it’s one that the Joint Commission focuses on in every hospital. If you’re in a solo practice, it’s up to you or your trained employee to make sure this is done well. If you’re in a big group practice, you probably have a team of folks that run this part of the operation. Either way, you should be knowledgeable enough about the HLD system to be able to ask the right questions and anticipate major potential pitfalls. You should also keep abreast of the latest developments with regard to endoscopy equipment. When you go to conferences, test out the different types of equipment there and develop good relationships with equipment companies so you can get the right items you need. Don’t just rely on your technician to know how to do everything. You need to know everything about the equipment you use so you can ask for the right things at the right time. You also need to be able to train new technicians when they come on board.
As a final note, I think gastroenterology is the best medical specialty there is (though I’m biased of course). I feel privileged to be a part of it. There are a lot of amazing opportunities and if you’re considering GI as a potential specialty, I highly recommend it!
Brent W. Lacey, MD is a gastroenterologist and founder of The Scope of Practice, a website devoted to helping physicians and other healthcare professionals learn to manage their businesses successfully and master their personal finances. He can be reached at editor@TheScopeOfPractice.com.
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