Gastroenterology Fellowship: Journeys, Quests and Career Choices.

 

 

scope in hand-gi-05

The NYSGE is a nationally renowned gastrointestinal society, but a huge driving force for our successful society are the fellows in training working at our various institutions. There are 539 total members in NYSGE, and 227 of them are fellows and residents in training. Although our fellows are strong clinicians and work tireless hours seeing patients, setting up carts, and performing emergency endoscopies in the middle of the night, they somehow find time to pursue academic interests and publish very interesting research.

In the past year there have been countless abstracts, papers, and publications involving our fellows. Although there are a multitude of publications, a selected listing here includes Anoop Appannagari, AET at Stony Brook, who published an interesting case in Gastrointestinal Endoscopy titled “Two endoscopic resection methods for the removal of an over the scope clip.” Lionel D’Souza, the BI-Mount Sinai AET recently published a case in ACG Case Reports Journal titled “A rare case of isolated pancreatic Tuberculosis.” Sunil Amin, AET of Columbia, helped publish the abstract titled “Longer time interval between ERCP and surgery associated with improved survival in pancreatic cancer patients” at ACG this past year. Nikhil Kumta (formerly the AET at Cornell) and Ming Ming Xu, the current AET at Cornell, who with other co-authors recently published a video in Endoscopy titled, “Submucosal tunneling endoscopic resection of a symptomatic leiomyoma in the proximal esophagus” which was also presented at the David B. Falkenstein Fellow’s Night. Shailja Shah, Mount Sinai Fellow won the distinguished poster award for her research in Ulcerative Colitis and the winner of the Peter Stevens Endoscopic Video Forum went to Sam Seroya of BI-Mount Sinai, both presented at this year’s Annual Dinner.

These extracurricular academic pursuits by our fellows are beneficial as they expand the knowledge and frontiers of Gastroenterology, but they also benefit the applicants as they are truly important markers of dedication, hard work, and persistence which are essential when applying for jobs. The light at the end of the tunnel comes quickly for many fellows, and after years of college, medical school, residency, and then fellowship come to a close, the real world rears its head come winter and spring for all of our senior fellows.

Job hunting can be a daunting task, and below are anonymous selected quotes of recently graduated fellows in the NY area to advise the current graduating fellows:

  • “The job search can be one of the most daunting tasks for any young physician finishing training. After having our career paths determined for us though the match process for the past 6 or 7 years, we are suddenly faced with the complete freedom to explore any type of practice setting in any location. This can be both amazing and terrifying. The first and most important step is to be honest with yourself about the situation that will be best for you and your family.”
  • “Use the interview to understand each practice model’s unique benefits and risks.”
  • “Ask around!  Discuss the position with your program director and people you trust.  Try to reach out to physicians who may have been recently hired by the practice you are interviewing for, or possibly who have left that practice in recent years.  Why did they decide to join that group?  Why did they leave?”
  • “Do not sell yourself short!  While you may not have experience outside of training, remember that the employers are seeking to fill the position.  They want YOU.”
  • “Have an attorney review your contract for loopholes.  Everything is negotiable.  If the terms are not equitable, continue to push for change so that they are.  You do not want to sign something that you will regret signing later on.
  • “Be flexible to an extent.  Some groups have specific needs and may ask if you would be willing to meet that need (reading capsules, learning nutrition/TPN, etc).  Consider these as these may still be good opportunities, but of course don’t sacrifice your goals/interests and settle on something you hate doing just to get the job.”
  • “Look at the dynamics and culture of the group (academic or private), could you see yourself fraternizing with these people for several years?  Are you proud to call them your colleagues?  Remember that these people will – for better or worse- represent the practice and take care of your patients when you’re on vacation, in the hospital, on call, etc.”
  • “Get a sense of the local admitting hospitals and ancillary services. Having an awful pathology department or radiologist will ultimately hurt your practice.”

 

Demetrios Tzimas, M.D.
Assistant Professor of Medicine
Advanced and Therapeutic Endoscopy Service – Director of Medical School GI Pathophysiology
Division of Gastroenterology and Hepatology  – Stony Brook University School of Medicine

Controversies in GERD Management

Gastroesophageal reflux disease, or GERD, is defined by the Montreal Classification as “a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” This characterization has always been intentionally broad, as symptoms of GERD can vary widely in patients, and the frequency of symptoms does not necessarily correlate with the quantity of reflux in an individual patient. To further complicate matters, only certain patients have long-term esophageal injury from GERD. Progression of GERD to Barrett’s esophagus and even esophageal adenocarcinoma can occur, but the majority of patients with GERD do not develop these long-term sequelae. In patients without concerning esophageal injury, and accumulating data on the potential risks of long-term proton pump inhibitor (PPI) therapy, how are we to think long-term about their reflux disease? If the symptoms are not able to be managed with dietary and lifestyle changes alone, should we now be considering alternative medical and procedural therapies in more of our patients?

To have a chance to answer these questions, I believe it is vital to step back and ask: why does my patient have GERD? Sometimes, the answer is obvious: it could be a recent dietary change or weight gain, or a clear anatomic process at the esophagogastric junction (EGJ) such as a hiatal hernia. However, if the cause is not obvious, further evaluation of the mechanisms of GERD in a patient can be important. The attention and interest in the pathophysiology of GERD has been increasing in recent years. For example:

-Without a hiatal hernia, traditionally it has been unclear whether a low pressure lower esophageal sphincter (LES) may have a role in contributing to worsening GERD. In addition, with the advent of high-resolution esophageal manometry studies, other LES metrics, one being the “EGJ contractility integral,” are being deciphered to study the EGJ comprehensively. Still other technology, with impedance planimetry, is being studied to assess the compliance of the LES in patients with GERD.  

-There is a body of literature suggesting that the LES may shorten over time, and this decreasing LES length may be a surrogate for progression of GERD. Here too, esophageal manometry may be beneficial in determining the primary underlying cause of GERD.

-Transient LES relaxations have been a known mechanism of GERD for many years. However, the majority of evidence suggests that the quantity of these relaxations may not be the most significant factor, and GERD patients instead will likely reflux more when the relaxations occur. Thus, the physiology of the proximal stomach may have a function in GERD, and indeed an “acid pocket” has been described at the EGJ from which reflux can originate after a meal. The location of this reservoir may vary amongst patients.

There are many potential mechanisms for GERD, and these are but a few that have received recent attention. Work to decipher the major etiologies of GERD in patients is encouraging, and eventually we can hope for different “phenotypes” of GERD patients based on mechanisms.

Importantly, we know that an overall balance of symptom triggers (causticity of gastric contents, volume of reflux) and symptom modulators (ability to clear reflux, tissue sensitivity) exist to create the condition of GERD. There are a variety of technologies now that attempt to quantify reflux in patients and correlate that reflux to particular symptoms (wireless pH as well as catheter-based pH and impedance-pH testing), and even focus on the chronicity of reflux in an individual patient (mucosal impedance testing). Further study of these technologies is expected to improve our categorization of GERD patients. Lastly, our options for treating GERD continue to widen, at the same time there is increasing physician and patient concern over long-term potential adverse consequences of PPIs. There are several modern procedural options for treating GERD, with both endoscopic and laparoscopic approaches emerging in recent years.

So how should I treat my patient with GERD on long-term PPI? My approach has always been: if there is no clear indication for indefinite PPI, the goal should be to decipher if there is a therapeutic option that will allow the patient to stop it. This may be a dietary, medical, endoscopic, or surgical approach. Thinking long-term about GERD coincides with considering its mechanisms. In the current landscape, a meticulous individualized approach to care, with a concise discussion on the risks and benefits of both medical and procedural therapies for GERD, is warranted.

As we improve our ability to categorize and “phenotype” patients with GERD, as well as use our motility, pH, and impedance technologies to assess GERD in individual patients, carefully done studies should allow us to develop appropriate diagnostic and treatment algorithms. Certainly, not every patient with GERD will be expected to improve with an LES augmentation procedure, but the goal will be to answer: which patients should get which procedure? As of now, we know that the patients that do best with LES surgery are also the patients who respond best to PPI. We have to do better than that. In the coming years, I expect that we will.

 

Abraham Khan, M.D.

Director, Center for Esophageal Disease

NYU Langone Medical Center