Advice on advanced year

[GastriqueGraffin]

If many of the community private practice jobs I’ve been interested in have stated that they want someone to do general GI with ERCP, is it still worth doing a 4th year just for that ERCP experience? I’ve asked something similar in the past but I really want to hear from someone with personal experience. I’m really on the fence about applying this year.

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[Scope guy]

number of ERCPs performed in a year in a community hospital will be <100 dependent on catchment area. if there is already a partner doing ERCP, you will likely do only half of those. Its very well known that high volume ERCP proceduralist has better outcomes compared to those performing <50. you will be wasting your skills in a community based practice with just option for ERCP. Many advertise EUS welcome but in reality they dont have the equipment or volume for EUS. reimbursements for EUS have fallen that many practices now choose to refer them to an academic center. If you do advanced, choose a place that will give you option for both ERCP and EUS, check with them the volume. If they want you to just take biliary call but wont feed you outpatient ERCPs, then you are taken for a ride.

 

[GastriqueGraffin]

number of ERCPs performed in a year in a community hospital will be <100 dependent on catchment area. if there is already a partner doing ERCP, you will likely do only half of those. Its very well known that high volume ERCP proceduralist has better outcomes compared to those performing <50. you will be wasting your skills in a community based practice with just option for ERCP. Many advertise EUS welcome but in reality they dont have the equipment or volume for EUS. reimbursements for EUS have fallen that many practices now choose to refer them to an academic center. If you do advanced, choose a place that will give you option for both ERCP and EUS, check with them the volume. If they want you to just take biliary call but wont feed you outpatient ERCPs, then you are taken for a ride.

I totally agree with what you’re saying but as a 1st year fellow in June I have not reached out to any jobs directly but just looking online at posting I am very concerned about how many require or strongly prefer ERCP. I don’t know if this will be an issue in a year or so when I finally start applying but I’ll need to make a decision on advanced before then.

 

[Gastrapathy]

The first question is do you want to be a lower volume stone/stent level 1 ERCPist. They want that because it allows you to share call. The ivory tower doesn’t think you should exist and will happily line up to testify against you (Freeman basically says as much at his standard ERCP complications lecture).

That said, there are lots of these folks and most are getting only an exposure to ERCP in training and then OJT. You can be credentialed in ERCP regardless of your fellowship volume. These are the jobs you see advertised but the good jobs are never advertised anyway. You’ll be highly employable as a general GI without ERCP.

 

[IM2GI]

As above, they want ERCP but not EUS. They want ERCP so you can take ERCP call and so they don't lose that business. Most general guys out-bill advanced guys from a global perspective.

Don't do a fourth year unless you want to do EUS and advanced biliary cases. That said, the market for those jobs is fairly saturated as you don't need that many of those providers within a given health system/group. EUS also kind of sucks and it takes a certain mindset to be good at/enjoy it. It is the most different from any technical thing we do with by far the steepest learning curve.

There are less and less programs blessing you to do ERCP after 3 years. You will have complications and someone may sue you along the way. I think it is increasingly sketchy medico legally to be a fresh grad doing ERCP after 3 years without a fourth year.