Five things I wish I knew before I went into practice as a gastroenterologist

gastroenterologist

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 that were intentional about teaching me clinical and non-clinical things 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, and I hope they help you prepare for yours.

1. I wish I knew that control of the endoscopy suite matters

My first job after fellowship was at a small hospital in Florida.  I was the only gastroenterologist there.  Unfortunately, I found myself in an incredibly awkward organizational structure.  

My clinic (space, staff, supplies) belonged to the Dept. of Medicine, which made sense.  However, the endoscopy suite, including space, staff, equipment, and supplies, belonged to the Operating Room (O.R.).  

Since I belonged to the Dept. of Medicine, I had no actual authority over the activities of the endoscopy suite.  This was incredibly frustrating!

The first O.R. Dept. Head I worked with had a real chip on his shoulder about the endoscopy suite and sought to block me at every turn.  Within a few months, I had increased productivity by 40% and was doing more procedures than every other physician at the hospital.  

It didn’t matter, though.  He made it his mission to try to thwart my efforts.  Fortunately, my Chief of Medicine saw that I was doing great work and she helped get me out from under his thumb.  

Once that Dept. Head retired, much to my celebration, the next Dept. Head and I got along very well.  He helped support my mission to serve the maximum number of patients, and I helped make his division the most productive in the hospital.

Not having authority over the activities of the endoscopy suite is really a terrible position to be in.  If you’re looking at a practice where this is the case, keep looking!

You need to retain both the responsibility and authority over the endoscopy suite.  This includes ordering supplies, upgrading equipment, designing your space, and hiring/firing.  

Don’t find yourself in my predicament, which was having responsibility for the endoscopy suite with no authority to enact the needed changes.  

2. As a gastroenterologist, half of my patients have irritable bowel syndrome (IBS)

IBS is the bane of our existence, according to many gastroenterologists.  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 in someone’s life.  

I actually love my IBS patients, and I genuinely enjoy caring for them.  However, I know that not everyone does.  You will see a lot of IBS patients in practice.  

IBS is tricky 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 these.

Error #1: Never making this diagnosis

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.  

Also, don’t just send them 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 this 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: A gastroenterologist “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 screening colonoscopy 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 that situation, you really can’t afford that either.  

If you’re in a large group practice, you can and should treat the challenging IBS patients.  Take some of the burden off the primary care docs.  They’ll appreciate you and will refer more patients to you.

Error #4: A gastroenterologist not believing in the use of SSRIs to treat IBS

Using “anti-depressants” isn’t a cop-out in IBS.  I know some GI docs don’t believe in using SSRIs, but they’re just 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!  It’s wrong to avoid this option just because you “don’t believe in them.”  

The biochemistry is clear: IBS has a serotonin-mediated origin.  The SSRIs will serve your patients well.  Don’t fear them!

3. Physicians other than gastroenterologists 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 primary care physicians and surgeons ask me my thoughts about them doing these procedures.

My general answer is, “It’s a bad idea.”  If you don’t have a lot of experience doing these procedures, 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.  

Full disclosure: the surgeons at my facility do some of their own colonoscopies.  We’re in a unique situation in that we have only one gastroenterologist to serve our patients.  Thus, my capacity is severely limited. 

I love working with our surgeons and genuinely don’t mind helping them.  But, if you’re in a larger metropolitan area where there are a lot of gastroenterologists, then the surgeons and primary care docs generally don’t do their own endoscopic procedures.  

Part of that is because of the overhead expenses associated with having an endoscopy suite.  Mostly, it’s because patients expect a high level of expertise with the person performing the procedure.

Also, you’re not getting paid if you take extra time to go help one of these non-GI docs doing 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. Advanced-level providers make a gastroenterologist a LOT more productive

In both of my last two jobs, I had a nurse practitioner working with me.  In both cases, having them on board dramatically improved my productivity.  

With an N.P. or a P.A. helping you in clinic or the hospital, you can be in the endoscopy suite more, which pays better.  Your wRVUs will go way up because you spend a greater percentage of your time in the endoscopy suite.  You also expand your clinic’s capacity by having another provider who can see patients in clinic.

There seems to be a lot of angst from physicians about “N.P.’s and P.A.’s taking over our jobs.”  I think physicians need to simmer down, especially gastroenterologists.

I love working with our N.P.’s and P.A.’s!  

They make my job easier and more productive.  Functionally, I can be in two places at once by having a well-trained physician extender working with me.  

Yes, you do need to invest time in mentoring and teaching them, but it’s worth it!  The ones I work with are amazing at their jobs and eager to learn.  They also tend to not have a chip on their shoulder, which is more than can be said for a lot of physicians.  

Patients love them too!  N.P.’s and P.A.’s tend to spend more time with their patients, and they tend to connect with their patients well.  Yes, some patients get bent out of shape over “not seeing the doctor.”  However, if you work with people you trust (like I do), you’ll have the confidence to tell patients that they can find another G.I. clinic if they have a problem with that. 

5. A gastroenterologist 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.  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.  

Take ownership over this area of your practice.  Don’t delegate this responsibility to your techs.

Final thoughts

I’m biased of course, but I think gastroenterology is the best medical specialty there is.  I feel privileged to be a part of it.  There are a lot of amazing opportunities and it’s well worth it.  

If you’re considering GI as a potential specialty, I highly recommend it!

If you’re a GI fellow, welcome to our ranks!  Take heed of these five things listed above.  You should also ask other gastroenterologists to tell you what five things they wish they knew prior to starting practice.

The more you know, the better prepared you’ll be.  I hope you enjoy GI as much as I do!

Further Reading

Please leave a comment below and tell us what you want to know about being a gastroenterologist.  If you’re a gastroenterologist, please share one thing you wish you had known before you started clinical practice.

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