Medical Specialties - Gastroenterology (2 Oct 2024)

SPEAKER_02 0:13

Hello everyone and welcome to another episode of Career Conversations brought to you by the Royal College of Physicians of Edinburgh Trainee and Members Committee. My name is Dr. Marilena Giannudi and I am on the TNMC, and today I'm delighted to be joined by Dr. Archie Coulter, who is also on the Trainee and Members Committee and is a gastroenterology registrar in Seven Deanery. And our episode today is dedicated to gastroenterology training. So Archie, welcome and thank you for joining me. Hi Marilena. The first question that I always ask is why did you get into your specialty? Can you tell me a bit about why you got into gastroenterology?

SPEAKER_01 0:54

I spent a long time not knowing what I wanted to do, and that kind of went right through foundation programme, ACC SEQ bed, and uh I had a year out post-ACCS as well. And I think it was a very long and slow process. A lot of jobs I was doing, whenever I do them, oh I love this. Yeah, I could definitely do this. So, you know, I went through the emergency medicine, oh yeah, this is great. Lots of fun, lots of activity going on through anesthetics, through ITU, all of these things I could kind of see myself with that hat on. I didn't love my time in medicine as much prior to that, but went on med-red road to in CT3. I always I was all of a sudden started like, actually, you know what, this is definitely my tribe, this is where I feel very comfortable, and you know, this is a job that I'm really actually enjoying doing, kind of med-redging at DGH, and then it was a case of deciding really what I was wanted to get out of specialty. I liked all the practical procedures that have been getting involved in along the way, whether that were things as doing ITU or anesthetics, or also like seeing other people doing procedures when I was in with other specialties. I wanted to still be doing practical procedures, I still wanted to be kind of dealing with really unwell patients, something with a lot of acuity, and I wanted something where it wasn't going to be just that. In my journey at that point, I also did enjoy having a bit of longer-term follow-up and I had my own a specialty that would be would be bringing all those things to me. And ultimately I was looking at both resp and gastro, and I think I applied for both, and ultimately I just won't feed into gastro for various different reasons. Mostly to use the I thought the procedures on that side of things sounded more interesting to me. That was my journey to it. So it was sort of a case of thinking about what I was wanting out of a job, and in that case it was wanting acuity, some long-term follow-up. So I wanted something that had a fairly broad base and you'd be dealing with a lot of different things. I didn't want it somewhere where I felt overspecialised and I'd worked someplace where gastro gets involved in GIM, but also I'm kind of aware of gastroid fault covers quite a wide spectrum of other illnesses as well. I found that very appealing too.

SPEAKER_02 2:34

What is a typical day like because of what you've said of how broad it is? Maybe if we think about what a typical week may be like for you now.

SPEAKER_01 2:43

There's a lot of different roles you might find yourself doing as a gastro registrar. Broadly, most jobs you're going to be doing in training, you're going to have a number of these elements in different amounts. So you might have a day or weeks where you're doing just referrals, and that works differently depending on where it works. That means often going down to AMU with one of the consultants, seeing new patients are being referred in with gastrotype problems, but then much for the rest of the day dealing with emails or whatever e-referral system you have, answering questions either remotely or going and seeing other patients who are kind of cropping up throughout the day. Some days of a week you might be doing that. Other times you might be just simply dedicated to a ward job. On most of the jobs I've been doing in recent years, it's not a huge part of it. You might find maybe between a quarter and a third of your time you might be involved in something involving word work on gastro, and that will be, in some ways, quite similar to any other kind of ward job where you're going to be leading ward around seeing patients. You might then spend part of the day in clinic or part of the day in endoscopy, depending on what the setup is there, but also supporting juniors on the ward. And then of course, some days you'll be having clinic head getting on top of clinic academic as well. Usually you get a bit of dedicated time towards that. And of course, endoscopy training. To give the example, this week I had a clinic in the morning on Monday and then a training list in endoscopy in the afternoon. Followed by on Tuesday, there was actually the same thing again. There's a clinic in the morning and a training list in the afternoon. Then one day it was a PRCP list followed by a service list. I'm now signed off in Upper GI Endoscopy as well as doing endoscopy training, doing a certain amount of service lists. And then it was adminton clinic yesterday, so it was a very clinic-heavy week this week, but some weeks I might find myself doing an entire week of referrals. Other times you might find yourself usually where I am currently, if you're doing the rewards you were doing for a week, which makes sense for continuity.

SPEAKER_02 4:18

And if you don't mind, I think we should just focus slightly on the procedure side of things. When we kind of declare ourselves as medics, we then subdivide into two groups. The medics that really don't want to even think about procedures, and the medics that say I can't do anything without having a procedural element. And then obviously within that subdivision, for example, I'm a cardiology trainee. I thought I wanted to do intervention, but now I've pretty much set on the fact that I don't want to do intervention and that's okay with me. But what are the practical procedures that you get trained in in gastroenterology? And is it that all gastroenterology trainees, once they CCT, need to be skilled and doing those procedures?

SPEAKER_01 5:02

As a basic, it's part of your CCT and part of your progression that you need to be able to do gastroscopy at a very minimum. Everyone would usually start doing training in OTDs in ST3. You know, you'd expect to get signed off towards the end of ST3 or sometime in ST4 with that. And then ideally you can be doing service lists as well, so doing your own independent lists after that. And then historically, most gastroenterologists would also do colonoscopy. But I think since the shorting of training, the shape of training, it was already before the shape of training. Most people weren't getting quite fully signed off by the end of training, or at least there's a large number who weren't being. And that's gotten much worse since the shape of training. So not everyone will now undertake colonoscopy training. I think if you want to pursue the hepatology pathway, a lot of people will drop colons as part of that. And then there's lots of other stuff you might get involved in as well. So for example, if you want to be doing ERCP, that will take extra time and off and you need a fellowship to get fully signed off on that now. Or for example, endoscopic ultrasound are other kind of procedures that people might get involved in. But in answer to your question, the only procedure that you will be expected to do and everyone will need to be signed off in as part of gastro training will be OGD. And I think if you're pursuing luminal gastroenterology, you really want to be doing colons as well, unless you're, you know, really becoming like a dedicated HPB person. So gastroscopy is a minimum, but then it kind of depends on what your own ambitions are as to what you're pursuing beyond that.

SPEAKER_02 6:12

In terms of your on calls, now I gather they may be different if you're based in a tertiary centre and in a district hospital, but what do your on-calls tend to look like? And what do you get up to during your on calls?

SPEAKER_01 6:24

For me, in Severn there's a lot of very large DGHs within the region and even the university teaching hospitals, they don't really have dedicated gastroencalls. I trained in Edinburgh previously, and certainly I remember people would have on calls in their specialty. We don't have that at all in my part of the southwest at least anyway. So it's not something I can really usefully answer on. So my on-calls are essentially general medical on calls, and there's no gastroen call part of it for us.

SPEAKER_02 6:46

So if you have, for example, someone coming in within a GI bleed.

SPEAKER_01 6:50

Out of hours, GI bleeds will be obviously managed by the acute medical take. And then if someone feels they need a GI bleed being managed out of hours, that's a case of calling the gastroconsultant on-call. That said, it's not an exact on-call element, but when you're kind of seeing referrals, I guess is an element of dealing with those kind of problems during daylight hours, where you're available for taking referrals and what's going on. I don't consider it as an on-call, but yes, you are kind of seeing referrals during the day, I guess.

SPEAKER_02 7:13

And I knew that you mentioned that your pathway was probably not 100% set on gastro until you got there. But if one of the trainees who perhaps is trying to make up their mind and is toying with the idea of gastro is listening to us, what kind of advice would you want to give to them about how to become involved in the specialty?

SPEAKER_01 7:35

How to get involved in the specialty, I think it's quite good to you to try and get yourself a job on that, where we see more of what the specialty has to offer. But I think at the same time, even at the IMT level, you're not going to get a full picture of what the specialty really has to offer. I feel that a lot of training, you know, whether it be foundational or IMT type jobs, often my feeling is the job that you see as a more junior trainee can often be quite different from what you're seeing doing as a more senior trainee. And obviously my work is extremely varied indeed, and that's a lot of fun. But I think at the more junior level you're not seeing that. So I think it would be quite useful if you can try and get some time just to some taste, just so you can see what the specialty actually has to offer and have a bit of a clearer picture of what goes on in terms of going to endoscopy, trying to get more into the kind of clinics. And I think it probably wouldn't hurt to try to get involved in projects related to specialty. Turning up the BSG is really interesting as well. Quite a good way of seeing what's going on in the specialty and all the kind of current topics in areas of interest. I think if you were just setting out and wanted to see what a career in gastroenterology might have to offer, however, the BSG runs fantastic taste course. It's a couple of days and it gives great insight into career and gastroenterology, as well as experience of things like endoscopy simulators and advice around applications, and that's something that I attended myself in FY2. Uh so long before I actually was really seriously considering a career into gastroenterology. In terms of my own self, I had a bit of an inkling and wanted to pursue gastro during CT3 of ACCS, so I tried to use some of my time to get down to endoscopy and see a few procedures and actually go to a couple of MDTs and journal clubs and things that were available just to get an idea of what was going on in gastro at that time. But I feel like I'm not sure I might necessarily answer that question very well about what one can do to pursue a career in gastro.

SPEAKER_02 9:04

I think you're right though, and I think that's what we've heard from listeners time and time again. If you're interested in a specialty, just talk to one of the registrars on the specialty, ask if you can shadow them. It's just about putting yourself out there. Everything else you need is on the checklist when you apply for the job. So you know your audit, your quality improvement projects, teaching, or however that changes on an annual basis. I'll try and link that to the podcast show notes for anyone listening. But I do think as long as you start making contacts within that specialty, those things will fall into place.

SPEAKER_01 9:37

If you do end up having a bit of time out between IMT and higher specialty training, or between Foundation and IMT, there are lots and lots of really good fellow posts out there. I've seen lots of folks in our region doing jobs where you know they're getting involved in Dosco and actually having a proper feel of what it's like on the red route and gastro. I've seen for a lot of friends in Collywood that's been quite interesting and useful stepping stone to getting gastro jobs later on.

SPEAKER_02 9:57

I guess the only thing that I'll add to that is I was terrified of taking time in between training jobs. And I discussed it with one of my consultants, and she just looked at me and she was like, Marlena, why? That's that's experience. No one can take experience away from you. And I think sometimes we feel forced to take that next training number, to take that next training post. And if it's not the right thing for you, then that's totally okay. If you want to see what it's like in a specialty before committing yourself to that lifelong, why shouldn't you have the opportunity to do that?

SPEAKER_01 10:32

I took time out post-F2 and post-ACCS, and I was glad of both those years, really. Although my post-ACS year was most expensive doing COVID-related stuff, I think taking you to time to actually be absolutely sure what I wanted to do and get getting fully behind it was right for me. It took me a long time to make a decision, but it was one that wanted actually made a decision, so I'm absolutely certain of this. I'm I'm very, very happy to continue pursuing this and being a bit of an evangelist for specialty as well, really.

SPEAKER_02 10:54

And that's the most important thing. Do you think that you need to have specific skills to be good at gastroenterology? Or what kind of skills do you think would benefit a gastroenterology registrar and later consultant?

SPEAKER_01 11:08

So I think it's helpful to be someone who at least has an inkling that you want to be doing some kind of practical stuff. I think if you want to have a kind of entirely clinic-based or, you know, a very, very entirely hands-off job, I think there are perhaps some consultants who do less scoping or less practical stuff than others, but you're likely to be expected to be on a bleed rotor out of hours after CCTing. That said, I think actually it's one of things that I really enjoy about Gastro is where I've been working recently, you know, you go from trust to trust, job to job, and within trust, you do see a very wide variety of personalities, a very wide variety of approaches from those people who are extremely relaxed and hands-off to those people who are very, very conscientious and will be aware of every single result and be very involved with what's going on. So I think in terms of like styles and personality types, there's a very broad range in that. I don't think there's a single type that fits into the gastro tribe aside from the fact that I think you probably ought to have an inkling you want to be doing some practical procedures. There are lots of ways you can sub-specialise within it. That contributes towards the breadth of the consultant. So, you know, the fact you can be pursuing a luminal pathway, but within that going doing IVD, or you might be doing nutrition, you might be doing HPB medicine, or you might be someone who just focuses really on an upper GI dysmatility or might be your area of interest. Likewise within hypotology, there's many ways of doing that, whether you're in a kind of DJ setting or whether you're being a dedicated transport hepatologist, or indeed someone who is purely an endoscopist and that's what they do, doing all sorts of advanced endoscopies, take off like polyps and doing EUS and ERCP, etc. So there's because there's a very wide spread of roles and the skills that each of those might require can be quite different. There's a wide variety of personalities that you'll come across within it as well. If you haven't necessarily found your tribe on starting, you might well find afterwards.

SPEAKER_02 12:40

And I'm so sorry for my ignorance, but what is the luminal pathway? What does that include?

SPEAKER_01 12:46

Especially post-shape of training. They've essentially said we need to divide into two. So they want about 20% of gastro registrants to declare that they'll be pursuing dedicated hepatology training and finally be called a hepatologist versus the remaining 80% of us who will be luminal gastroenterologists. And so the key difference really is almost the default, and hepatology is something you need to be doing something a bit extra for, and that's that you need to be doing a bit of time in a dedicated level three liver centre, so somewhere where they're doing liver transplants. And so that's a bit that can be a bit of a challenge for some people in some regions, because in the South West, for example, we don't have a level three liver centre. We only have three level two centres within the several deanery. But if you want to be getting involved in a transplant centre, that means that you need to be going to London or Birmingham or Cambridge. We have a programme in the South West where you can do six months in the Bristol Royal Infirmary and six months in London. But it does mean, of course, that you know, if you are very settled in your region, say for example you have kids or something like that, that actually might present a little bit more of a hurdle or a bit of a barrier. So if you really want to be pursuing livers, that can present a little bit of a hurdle for some people if you need to move out of area. So in Edinburgh it's easy enough if you're working somewhere where they have all the services within one hospital, but within one city. Not as easy if you're other areas of the country where provision of service is somewhat different. Also, in the northwest of England there's no transplant centre there, which is a huge area. And so once again, I'm not quite sure what the setup is there is. So for people who want to pursue livers, it's a little bit more of a hurdle that you need to be spending a bit of time doing an advanced training program.

SPEAKER_02 14:08

At what point in training do you need to declare that you're either going to do hepatology or the luminal pathway?

SPEAKER_01 14:14

By the end of ST5, it's something I really flip-flopped on over time. I uh went into thinking that I want to do livers, then at the end of ST3, actually, maybe maybe luminal, then went back to livers for a long time. I think I finally planned my feet on the luminal side of things, but only really within the last six months. I was kind of post-ST5 actually. There are a number of reasons for me why that was the case. For a while I said that I might try and pursue livers without leaving the region, because I was one of those trainees who didn't really want to go out of region for an advanced training programme. So if I wanted to pursue livers, that was going to be a bit tricky. And I'm aware that some people do primarily livers even though they've not spent time in transplant centre, and that worked well in a DGH context. But for me, I was really enjoying colonoscopy, and it was something that some people within the region were kind of pushing, if you want to be pursuing livers, to not be pursuing colons. For those two sides, I think for me, I was uncertain between luminal and live, but I was really enjoying colonoscopy. But I should say that that's not necessarily replicated everywhere, and I think how people approach these things is going to be different from place to place. But certainly there are things you need to think about if you're pursuing livers. The original question was, of course, what is luminal? So luminal is everything that's not really livers in a sense. A lot of the job is going to be kind of general gastroenterology, so in clinics, you might get preferred patients with chronic diarrhea or weight loss or chronic constipation or new anemia. But a lot of the bread and butter of what you're going to be dealing with will be will be inflammatory biologists and lots of your follow-up patients will be that, but you might be seeing other stuff like celiac disease. Or you might be dealing with functional gut disorders, so what we're these days calling disorders of brain gut interaction. Or perhaps cases like recurrent iron deficient anemia. HPB cases might also occasionally find their way in, depending on where you work. Certainly the nature of luminal work can be quite varied, depending on both where you work and if you have any particular subspecialty within that.

SPEAKER_02 15:46

Following on from that to what is usually my last question, if you can, obviously abiding by patient confidentiality, do you have an interesting case that you can perhaps talk us through that may really highlight the amazing specialty that is gastroenterology and your involvement in it?

SPEAKER_01 16:05

So in terms of thinking of interesting cases, there are plenty of things I potentially choose from, whether that be particularly neat nargi bleed or interesting foreign bodies removed in endoscopy or chasing diagnostic hen's teeth either in inpatients or the clinic. But I think for me, my most memorable case so far in training is actually something that was far more prosaic, and that was one that was encountered on the hepatology clinics during my ST4 year. It was near the start of the year, and there was a patient being referred from his GP with a suspected new diagnosis of cirrhosis. The GP had already done pretty good work for him. He'd had a non-invasive liver screen, which was all fairly unremarkable, but his ultra-tanchoded asterotic looking liver. And all in all, based on the referral, it looked like it was going to kiss a child Acerrosis. As is often the case in these individuals, this gentleman has a history of quite significant alcohol excess, since he was drinking around eight cans of cider per day. But in spite of this, he had a young family and he was still holding down a job fairly successfully. This case is one that came on the back of an earlier discussion I'd had during that rotation of one of the consultants who was encouraging me in cases like this where the diagnosis seems pretty clear and there's no red flags for any kind of decompensation or anything else that might point you in other directions as to diagnose other investigations, to really try and make use of that time in that you have to have an intervention as to the root cause of the problem in this case and looking at working towards abstinence. And whilst one might not feel qualified as a psychologist or anything like that for that kind of intervention, nonetheless, your input as a doctor at that time of diagnosis can be really impactful for these patients and make a real difference. And so trying to put this theory into practice, that's exactly what I did. And I had a discussion with him, explaining to him about how, whilst the signs were that it was quite early, that he definitely did have a diagnosis of cirrhosis, and the good news in this case was that being quite early, there's a chance that he were to stop drinking right away, there's a good chance for some recovery, and he might remain symptom-free long term. But that said, with continued drinking at that level, it was very likely it's going to have a significant impact on his health, the progression would be found inexorable, and they could have other impacts it was going to have on the life that he currently had. And he was very receptive to this at the time. It's not always the case, but certainly in this case, he was very, very interested into what I had to say, and following up in four months' time, and by this time it'd stopped drinking completely, and he was feeling much better in himself and very grateful that we'd be able to identify this early on. But the story doesn't end there, and had the new diagnosis of cirrhosis, he was enrolled at screening, and lo and behold, on one of his subsequent Alchad scans, there was some water lesions picked up. And I went and sent this for an MRI scan, and it showed an early hepaticellary carcinoma, which we then were able to send on for MDD discussion, and as a result of this, he went on to have a curative treatment for it. And I think why this case is an important and a memorable one for me, really, is I think there's an entire potted history of the story of beginning to end of the kind of pathway in that particular case. And while it's a case where you really do feel like something you've done within your day-to-day clinic has made a real impact on someone's entire health and life trajectory. And simply by doing a lot of those basic things, there's simply things like actually having that discussion with the patient, following up in clinic, having the appropriate screening and then being able to act upon it, added up to something that was life-changing for that particular patient. And I think that's one of the many aspects that I love about the job in Gastro, and that's the fact that you've got the longer-term follow-up, the fact that you do occasionally, well actually often CPA patient is getting better, you can see a real impact of what you're doing for your patients. But that goes alongside a lot of the acuity you'll come across, especially amongst the inpatients, and also the interventional aspect. So I think in terms of being able to offer a really interesting and varied job, gastro takes an awful lot of beating.

SPEAKER_02 19:25

Thank you so much, Archie, for your very honest approach to your career in gastroenterology and for guiding us through what it actually means to be a gastroenterologist, how to get involved in this specialty. I'm sure our listeners are very grateful for that. For anyone listening, please feel free to listen to our other podcasts on this channel. If you're unsure about what specialty to go into, we cover lots of different specialties and have lots of different episodes. Equally, if you want to broaden your clinical knowledge, we've got our other podcast channel, Clinical Conversations, where we discuss common situations that you may be confronted with whilst you're on call. Archie, thank you so much for taking the time to talk to me today.

SPEAKER_01 20:07

Thanks, Brian Lina.

SPEAKER_02 20:08

And thank you to everyone for listening.

SPEAKER_00 20:29

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