34: Community Based Interventional Gastroenterologist

Session 34

Dr. Sushil Duddempudi is a community-based Gastroenterologist who specializes in interventional endoscopy. He has been in practice for ten years now and specifically as an interventional endoscopist for the last seven or eight years. He used to be in academic hybrid private practice. Check out what he thinks about the field and what you should be doing if you're interested in this field.

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[01:45] An Interest in GI and Interventional Endoscopy

Dr. Sushil Duddempudi knew early on that he was going to be in a procedure-based field. It's a running joke in the field that GI people aren't smart enough to do anything else so they use procedures as much as they can. Then leave the complex stuff to the nephrologists, neurologists, and everybody else.

Sushil started residency leaning towards cardiology until realizing he hated EKGs. So he gravitated towards the GI field. He says it's not uncommon for students somewhere during their intern year where they're interested in one area. Once he started the GI fellowship, he knew he was into doing procedures. He found interventional endoscopy as a good fit for him because it lets him do procedures most of the time. But he still has this continuity with his patients which he loves. So about two-thirds to three-quarters of his time is spent doing procedures. Then maybe a quarter to a third is spent in the office seeing patients.

"GI is a pretty cut and dry field compared to some of the other fields."

Sushil describes they usually have a definitive diagnosis early on after seeing a patient and he likes the finality of it. GI borders that surgical mindset and a lot of GI's have mindset.They see a problem and they want to take care of it. Also with GI, there is finality. If the patient has rectal bleeding and you had a colonoscopy then you'd have an answer 99% of the time. When patients have abdominal pain unless it's functional, most of the time, they come up with an answer.

Moreover, Sushil likes the opportunity to do procedures. Other specialties he did consider include ENT or Neurology which would have probably worked for him as well or one of the subspecialties that are procedure-based. Ultimately, he ended up in GI.

[04:40] Traits that Lead to Being a Good Interventional Endoscopist

Sushil describes how many of those starting GI fellowship often say they want to do interventional endoscopy. Then over their first year or two, they'll select out.

"You have to enjoy doing procedures."

Some fellows he has worked with and trained over the years come in with a certain special knack. Some people just have good eye-hand coordination better than others. 90% of it can be taught and trained. But the people they look up to in the field are born with a little bit of it. This is what Sushil differentiates them from the rest. They are the guys doing the hard core cutting edge stuff. So it's a bit of something you bring within you into the fellowship and then 90% of it is just practice.

[06:15] Patient Types and Typical Day

If you're an academic interventionalist, you can tailor your practice to focus on that. This could mean 75% of your practice doing procedures. Community-based interventionalist flip it all the way around. In gastroenterology, the bread and butter is still colonoscopy.

If you're a community-based interventional endoscopist, you could be doing around 25-75% general and then the remainder is advanced interventional endoscopy. Then as you get older and you've done all the cutting edge stuff and you want to settle in a little bit, you can then focus on general gastroenterology. Then you can do the interventional stuff maybe 25% of the time.

For general GI, the younger groups tend to come in with more functional disorders and abdominal pains. As they get older into their 50's, they start to do a lot of colonoscopy screenings. Also in the 50's and 60's, they start to see a lot of GI cancers.

"Interventional endoscopy is very focused on GI cancer. That's where a lot of the techniques are being used."

For general gastroenterologists, most of them will do roughly about a half day in the morning. They start at around 7 or 8 to about 12 or 1pm doing endoscopy. Generally, you are in an outpatient surgery center. Then the afternoons would be spent in the clinic.

Sushil says that more and more gastroenterologists are coming out of the hospitals and staying in their office in surgery centers. Moreover, a new breed of GI hospitalists are starting to happen where you're focusing on inpatient training. This happens less in the big cities. But generally it's a mix of outpatient procedures an outpatient office visits which is 90% of what gastroenterologists do. While the other 10% would be composed of inpatient.

If you're an interventional endoscopist, you'll me a little more focused on the in patients because that's where a lot of the work comes in. This involves cases like bile duct construction, GI tract tumors, etc. Although they see this in the office, a lot of work comes in the emergency room. In Sushil's practice, the way they do it in the group is that most time is spent in the hospital early on. Then after two years, you will transition out to the outpatient side. So the new guys coming in cover all the hospital work. Then the partners are just focused on the outpatient work.

"Like many practices, it transitions over time based on your interests, time constraints, the type of practice you have."

[10:56] Work-Life Balance

Sushil didn't actually feel he had any work-life balance. But he would say that in general, interventional endoscopists are in the hospital the latest.

"It's definitely a field that you're committing extended hours compared to general GI guys."

This is because more of your work comes in in the inpatient setting which is always unpredictable. Your day could be extended. And the procedures you do tend to be a little longer . They are a bit less predictable than a colonoscopy or endoscopy which you can do in fifteen-minute blocks. Interventional endoscopy procedures are a bit harder to put into certain blocks.

[12:30] The Path to Residency and Fellowship

For interventional GI, sometimes called advanced endoscopy, you do your three-year medicine residency. Then you do three years of general GI fellowship.

And then there is another year of sub-fellowship. This has actually has crept up in the last five to ten years. Currently, there is only one ACG-accredited post GI fellowship that is liver transplant. And there are are five non accredited which include interventional endoscopy, clinical hepatology, motility, inflammatory bowel disease. Interventional endoscopy is the most popular. Just a year or two ago, interventional endoscopy actually went into a formal match process. Previously, you just apply to all the programs in the country and you get interviewed, you get offers and pick one. Now, it's a formal match process. It's also expected that in the next couple of years, it will be a fully accredited ACGME fellowship just like interventional cardiology.

If you didn't do the special training, you wouldn't be able to do certain procedures in GI. Currently, a lot of the older generation gastroenterologists still do ERCPs. Most of the younger people don't because they did numbers of them on their training of all GI fellows. So once it comes to full fellowship and board certification, it's expected that new trainees, if they don't do the actual training, won't be allowed to be allowed to do ERCP, EUS, and stents, and other interventional procedures.

Interventional GI fellowships are pretty competitive as Sushil describes it. GI and cardiology balance it back and forth when it comes to post-medicine fellowships.

"GI, number-wise, is the most competitive fellowship."

When Sushil applied eight years ago, there were only about 30 program in the country. Now, it's close up to 75 with about 35,400 GI fellows graduating a year. So he reckons only 25% apply for the advanced interventional training.

Although he wouldn't describe it as ultra-competitive but the majority of fellows he had trained that wanted to get it got in. Some may have to wait a year. But most fellows interested, eager, and did the right electives and the right types of research, got in. Sushil says you have to be focused and you need to take the right steps. Then there's a pretty good chance you're able to get into a spot.

[16:37] What Makes a Competitive Applicant

Sushil cites some qualities of a competitive applicant. He adds most interventional endoscopy directors look for people that have that extra knack (eye-hand coordination). Some of the hard skills are hard to train in one year. You need fellows that already have some experience.

Moreover, you are gauged through letters from your program director and the number of procedures done during your general GI training. He adds it's important to consider who you want to hang out with for the whole year.

"Unlike other fellowships, interventional fellowship is a one-fellow-a-year at any program."

So it's basically just you and you're generally working with one to three core interventional endoscopy faculty. So you're spending a lot of time with just a couple of people. Compared to general GI training, you're rotating around different hospitals and different services. So you work with a number of faculty. This is different from interventional endoscopy training since you're only focused with one person or two. So who do you want to hang out with for a year? Lastly, be nice to them on your interviews.

[18:30] Bias Against DOs and Working with Primary Care and Other Specialties

Sushil had the opportunity to train alongside DO's throughout his career. There have been some who were awesome while there have been some who weren't so good. This is also true for MDs and just with any other specialty out there.

But in terms of inherent institutional bias against DO's from the program directors, he doesn't think there is any. They don't look at it one way or another if a resident DO has gotten into general GI fellowship or interventional endoscopy. He adds that once you got to that level, you're met a lot of floors already. So he really doesn't think it's as relevant. Looking at interventional endoscopy fellows across the country, Sushil estimates that at least a third of them or maybe more are foreign grads.

In terms of working with primary care physicians, Sushil explains how fellows complain all the time about nonsense or bogus consults. But because he thinks his career has been mostly private or quasi-private settings, his view has changed.

"If a primary care or hospitalist called me, what I know and what they know are two different things."

While he may see it as a simple question and answer and it's going to take him two seconds, they may see it as something more complicated. If you'd ask Sushil the protocols or the GNC7 or up to 9 in primary care, he would have a tough time treating hypertension diabetes. That's because he hasn't done it so long. Hence, he looks at it as something they don't do very often. They have a question. They need some help.

So if a primary care physician has a question, the best thing to do is just call your local GI guy. Mostly, GI guys are laid back and not too uptight. His referral networks all have his number so they can always reach out to him whenever needed. As a specialist especially in GI (maybe more so in other fields), Sushil explains they're here to provide a service for them. They're here to do procedures and solve problems primary care physicians don't have the tools to solve. So when they call, help them out.

Other specialties he works with the most are general GIs and surgeons for interventional endoscopy. They work a lot with specialty surgeons like biliary and colorectal as well as interventional radiologists. Things they can't take care of generally go to surgery.

"That's where interventional GI has found its niche. It's at the interface between medicine and surgery."

They don't cut on the surface or on the skin but they do almost all of their cutting inside. Sushil describes it as the next evolution from open surgery to laparoscopic to robotic. Now there's a new thing called NOTES (Natural Orifice Trans Endoscopic Surgery). They're doing surgical procedures through natural orifices. As a result, there is less incision time, and less recovery time. They're still trying to figure out where the interface is going to be. Whether it's surgeons doing these procedures or interventional GI guys or a radicalization of medicine surgery that are going to end up being guys that do these types of procedures.

[23:57] The Most and Least Liked About His Specialty

What Sushil knows now that he wished he knew back then is that anybody on their feet a lot for doing procedures have got to have very comfortable shoes. He wished he had bought a quality pair of shoes right after training. He went from one brand to another until just back to regular sneakers.

What he likes the most about being an interventional endoscopist are procedures. He loves doing it. He loves the definitive nature of it. He likes that a patient comes in with a certain specific issue. And he's able to solve that issue most of the time. He likes to be able to give them definitive answer.

What he likes the least is being oftentimes the first person to inform someone that they have cancer since they deal with a lot of GI oncology. Sushil explains it's very rare that an oncologist has to give someone a cancer diagnosis. Usually by the time they're going to an oncologist, diagnosis has been made. Unfortunately, they get a lot of referrals for lumps and bumps on a CT scan and they're the first one to have to break the news to the patient that they have cancer. No matter how many times he has done it, he feels terrible every time. Colon cancers are pretty terrible but a lot of stuff they do in interventional endoscopy is pancreatic, liver, and gallbladder cancers which are generally not so treatable.

[27:00] New Changes in the Field of Interventional Endoscopy

Sushil sees the field as having this continuous evolution. If you went in for a colonoscopy for whatever the reason and they found a four-centimeter polyp, they'd stop the procedure. They'd work the patient up. They'd give them a referral to go to see a colorectal surgeon. About ten to fifteen years ago, that changed. Gastroenterologists started doing advanced training, becoming interventional endoscopists. They started doing removing those polyps out themselves. It's relatively rare that a non-cancerous polyp in the colon is sent for surgical resection. It's relatively rare nowadays for a procedure called a PTC to be done. This was a procedure done routinely after cholecystectomy. The procedures they're starting to do now are coaching more and more on the surgical fields. Patients often went for surgery before for a lot of GI polyps and tumors, etc. A lot of that is now done more being minimally invasive that's being done by laparoscopic surgeons. But even more minimally invasive than that is where a GI guy comes in.

"We're continually moving into this more and more non-invasive type procedures."

A their technology is getting smaller and smaller, they're able to go into areas that thy were never able to go in before.

Lastly, if he had to do it all over again, he still would have chosen the same thing. He enjoys GI and interventional endoscopy. He finds that it has the right blend of procedures but a little bit of continuity on the clinic side. He finds it as a good fit for him and what he enjoys. He doesn't think there's only one field a physician could go into but multiple fields. He thinks that people who enjoy the cerebral aspect of certain fields have a couple of different fields that would work for them. The same goes for those people that enjoy procedures. But all in all, Sushil has not complaints about the field he went into.

[29:40] Final Words of Wisdom

To those interested in going down this path, Sushil says it is never too early to start prepping your CV to get into GI. Consider that it's harder to get into GI given the numbers that is interventional endoscopy. When you start as an intern, go by the GI lab. Let the faculty know you're interested. Get involved. Get involved in research projects. They're not going to let an intern do that much. But there's always a need for someone to collect data, to collate data, to run statistics, to write papers. Get involved early on so that by the time you're second or third year role is around, you're seen as a junior fellow. You're part of the GI team. You're a resident but you're always hanging around the GI lab at any free time you have.

"It is never too early to start prepping your CV to get into GI."

Then when you move on to interventional endoscopy, the same thing. Go hang out with the interventional guys. Work on the papers with them. Come up with research proposals. Work on research projects, new ideas, new techniques. Be a junior interventional fellow.

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