GI is not just a “procedure” subspecialty. It’s a “cognitive” subspecialty too.

cognitive subspecialty

It drives me crazy when I go to conferences like the American College of Physicians and hear people talk about a “procedure subspecialty” vs a “cognitive subspecialty.”  

This nomenclature suggests that a “procedure subspecialty” is a “non-cognitive subspecialty.”  Don’t get me wrong, I love the ACP, but I do bristle at the insinuation that GI isn’t a “cognitive subspecialty.”

A “procedure subspecialty” typically refers to GI, Pulmonology, or Cardiology, which are  in fact procedure-heavy subspecialities.  “Cognitive subspecialties,” on the other hand, refer to disciplines like Allergy, Rheumatology, Infectious Diseases, and Endocrinology.

Allow me to make my case that GI should be included as a “cognitive subspecialty.”

A “cognitive subspecialty” like GI requires nuanced clinical decision-making.

There are several key errors that I see in non-GI physicians attempting to diagnose GI conditions.

Error #1: missing the second diagnosis

When I rotated in orthopedics as an intern, they loved trapping the interns with this question, “What is the most commonly missed fracture on a leg x-ray?”  

The answer is, “the second fracture.”  

For example, you might see the tibial plateau fracture and think you’re done.  But, then it turns out you missed the malleolar avulsion fracture at the other end.

Yes, it’s an unfair “gotcha” question, but the point is highly relevant.  

I coach my students and resident all the time that they have to be very careful in GI to avoid the “single diagnosis” trap.  

Don’t make the diagnosis of celiac disease and fail to evaluate for microscopic colitis.  If you diagnose someone with irritable bowel syndrome, you still have to prove they don’t have colon cancer.  Yes, I have seen that exact scenario!

It’s easy to fall into that trap, and a “proceduralist” would likely miss it.  Fortunately, the highly cognitive gastroenterologist will catch this and save the patient.

Error #2: making a GI diagnosis off of radiographic imaging

Radiographic imaging is important to gastroenterologists, and I love our radiologists for the support they provide.  However, it’s hazardous to rely solely on imaging tests to diagnose a patient.  

I regularly get calls about patients with symptoms that sound like infectious enteritis but who have “inflammation of the terminal ileum, consistent with Crohn’s Disease” on a CT scan.  

It’s important to treat the patient, not just react to the tests.  

Another one I see a lot is “large stool burden” on a KUB or CT scan that gets diagnosed as constipation.  I see this error made in people with normal stools or even chronic diarrhea all the time.  If you don’t take the time to think about the patient’s symptoms, you may make the wrong call.

Error #3: missing the diagnosis altogether

I get consults all the time for “odynophagia and dysphagia.”  That’s almost never the actual clinical scenario.  It’s almost always one or the other.  

Odynophagia, esophageal dysphagia, oropharyngeal dysphagia, and globus are all potential diagnoses under the heading, “trouble swallowing.”  They all present differently, and their differential diagnoses have almost no overlap.  

If a patient says they have “difficulty swallowing,” you may think they have esophageal dysphagia.  So, you might recommend esophageal manometry to evaluate further.  Unfortunately, the patient’s symptoms may actually consistent with oropharyngeal dysphagia.  It may turns out that they have Lou Gehrig’s Disease (ALS).  

An astute gastroenterologist can tease this out in the history and arrive at the right diagnosis.  That’s a highly congnitive process.   

A “cognitive subspecialty” like GI covers a wide variety of diseases.

Gastroenterology covers diseases in seven different organs: esophagus, stomach, small intestine, large intestine, liver, biliary tree, and pancreas.  I separate the liver and biliary tree deliberately because their pathophysiology is so different.  

We don’t even have procedures to diagnose every condition in every organ that we have.  It requires a lot of thoughtful deliberation to make the proper diagnosis for each of the myriad potential conditions of each organ.

There is tremendous variety in GI.  Before ICD-10 came out, GI had more ICD-9 codes than any other specialty, including Infectious Diseases. Each of the seven organs can get infections, malignancies, hemorrhagic complications, autoimmune conditions, anatomic aberrations, and many other problems.  

It’s a highly cognitive subspecialty that has to cover every one of those diagnoses.

A “cognitive subspecialty” like GI requires longer training periods.

Allergy, Rheumatology, Endocrinology, and Infectious Diseases require two year fellowships (not counting any research years).  GI requires three years.  Why is that?

I contend that it takes one year to learn to do the procedures and two to learn the diseases.  In reality, those activities are concurrent over those three years, but you get the idea.  

After a year of fellowship, my attendings certified me to do procedures on my own.  They still supervised, of course, but they didn’t have to be in the room on every procedure.  So, if GI is a “procedure subspecialty,” why wasn’t I done after that year?

The answer is that GI is a “cognitive subspecialty!”  Diseases like Crohn’s Disease, cirrhosis, and irritable bowel syndrome are incredibly nuanced with widely variable presentations and highly complex treatment options.  

One of my attendings joked that Crohn’s Disease is the reason GI fellowship is three years instead of two.  He’s not far off!  It took nine months of fellowship before I even started to feel comfortable managing Crohn’s Disease.  

How many doctors see the liver as a “black box?”  It’s 30% of the GI/Hepatology board exam, and many non-GI physicians think of it as “that thing that fails sometimes, so I call GI.”  I challenge anyone to go see a complex liver patient and claim that cognition is not required to manage them.

A “cognitive subspecialty” like GI can’t rely only on evidence-based medicine.

This point may be a bit controversial, but I stand by it.  Let me start by saying that evidence-based medicine is critically important, even in GI.  My point is that there are lot of clinical questions in GI that don’t have 10,000-patient clinical trials to provide a clearly defined algorithm for treatment.  

Hardly a week goes by that I don’t see something in my clinical practice that I’ve never seen before.  Sometimes it’s just an unusual variation on a common ailment, but it happens every week!

How do you manage Crohn’s Disease?  There are way too many variables to have a prayer of answering that question simply!  I’ll admit, that fact was frustrating in fellowship because I never felt like I quite had a handle on it.  

In practice, however, that variety is what keeps things so interesting for me.  Each patient is a bit of a mystery.  No, you can’t point to a specific clinical trial for every clinical quandary in GI, but I love that!  It requires me to critically think about each patient individually.  

There’s no “cookbook” for GI.  You have to think about each clinical question individually and come up with a new game plan every time.  

Final thoughts

I hope I’ve convinced you that GI is a highly cognitive subspecialty.  If you’re thinking of going into GI because you like procedures and you think that’s all we do, you should move on.  There’s a lot of variety and nuance, and not everyone who can sling a scope can hack it.  

If you like a mix of procedures and complex clinical decision-making, then this is the specialty for you!  

It’s high time for GI to take its rightful place alongside every other “cognitive subspecialty.”  I’m not a “scope jockey.”  I’m a well-trained, highly educated, incredibly capable clinician, and so are my GI colleagues.  

We are an elite group of cognitive and procedural physicians, so don’t discount this specialty as “just a bunch of proceduralists.”  There’s a lot more to GI than that.

Further Reading

Leave a comment below and tell us your thoughts about gastroenterology as a subspecialty.  

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