Family Medicine w/ Focus on GI

[Metamorphosis.DO]

Hey everyone. M1 here. I’ve had a lot of interest in GI as a specialty but ultimately plan on FM. I know some FM guys do routine colonoscopies. I’d like to offer this. Is it realistic to think I could do more clerkships and spend time with GIs in FM residency enough to be able to do diagnostic colon/endoscopios? Meaning not just routine?

I just want to know when that may reach a point of being frowned upon being that it wouldn’t be my area of expertise?

In addition to my interest in GI pathology and those procedures, I know they may help with compensation and I need to get these loans paid back ASAP!

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[deleted87716]

Why don't you just go into GI...?

 

[VA Hopeful Dr]

Yes, at the right residency program you can get enough experience to do endoscopy in practice.

But, you'll have to go somewhere to practice that has no GI doctors who will prevent you from getting privileged to do those or open your own practice and build your own endoscopy suite.

 

[Metamorphosis.DO]

Why don't you just go into GI...?

I’d rather see a greater scope (no pun intended) of pathology.

 

[kratos99]

It’s possible. One of my colleagues does sigmoidoscopies, IUD insertions, etc. Here in Canada, rural family docs do C sections, appendectomies, cholecystectomies, anesthesia, etc. during residency I once worked with rural doc who was also a vet so she’d deliver a horse during the day and do a C section on a human at night. Crazy lifestyle but definitely doable with the right training.

 

[FrustratedFamDoc]

A very important question to ask is where you intend to live and practice. If the answer is anything but WAY out in the middle of nowhere where there is no one else to do it, you're going to have to give your patients a very convincing answer as to why you should do it rather then the numerous gastros that are likely available. You'll also have to keep your numbers up for insurance/hospital privileges. It's a very uphill battle and for the most part, that ship has sailed, and will be even more so in 7 years when you can first practicing independently.

 

[InternistDO]

I agree with what everyone else has said--technically what you want is possible, but if you have any desire to live in or near a reasonably sized urban area it's probably out of the question. If you're worried about a limited scope of practice as a GI, nothing is stopping you from practicing some general internal medicine in your practice as well.

That being said, you're a first year medical student which means the chances of you changing your mind is quite high. See what you end up thinking during your clinical rotations--you may find procedures less exciting than you think, or you may find you prefer a more focused scope of practice (I was convinced I wanted to do EM for years--hence the username--but here I am doing primary care IM).

 

[Metamorphosis.DO]

I agree with what everyone else has said--technically what you want is possible, but if you have any desire to live in or near a reasonably sized urban area it's probably out of the question. If you're worried about a limited scope of practice as a GI, nothing is stopping you from practicing some general internal medicine in your practice as well.

That being said, you're a first year medical student which means the chances of you changing your mind is quite high. See what you end up thinking during your clinical rotations--you may find procedures less exciting than you think, or you may find you prefer a more focused scope of practice (I was convinced I wanted to do EM for years--hence the username--but here I am doing primary care IM).

This is good to know. Another reason I am not wanting to consider GI is the idea of 2 more years of training plus another round of applications for fellowship. I guess applying to med school left it’s mark on me. Maybe there is a veil of forgetfulness that I will pass through during the next few years and be more willing to do that when the time comes.

 

[InternistDO]

This is good to know. Another reason I am not wanting to consider GI is the idea of 2 more years of training plus another round of applications for fellowship. I guess applying to med school left it’s mark on me. Maybe there is a veil of forgetfulness that I will pass through during the next few years and be more willing to do that when the time comes.

I have bad news...it's 3 years for GI now haha.

I totally understand not wanting to do more training (I'm certainly not doing fellowship). You may find that you are satisfied with the smaller procedures of general medicine/primary care such as joint injections, suturing, IUDs, hemorrhoid removals, or central lines/paras in an inpatient setting in which case I'd recommend general FM and not worrying too much about scopes. Or you may find you really want bigger time procedures like scopes/ERCPs or cardiac caths, in which case unfortunately you're likely stuck with doing IM-->fellowship.

 

[FrustratedFamDoc]

This is good to know. Another reason I am not wanting to consider GI is the idea of 2 more years of training plus another round of applications for fellowship. I guess applying to med school left it’s mark on me. Maybe there is a veil of forgetfulness that I will pass through during the next few years and be more willing to do that when the time comes.

My advice is for right now is to keep you head down and focus on the immediate task at hand. You've got plenty of time to think about choice of specialty and everything that comes with it in a couple years. What you see as the current picture of Family Medicine will be quite a bit different in 7 years.

I will say that the landscape of medicine is increasingly trending towards midlevel encroachment and will likely be even more so by the time you graduate. It's hard to try to predict the future but surgical specialties, at least for now, seem to be pretty well insulated.

 

[Metamorphosis.DO]

I have bad news...it's 3 years for GI now haha.

I totally understand not wanting to do more training (I'm certainly not doing fellowship). You may find that you are satisfied with the smaller procedures of general medicine/primary care such as joint injections, suturing, IUDs, hemorrhoid removals, or central lines/paras in an inpatient setting in which case I'd recommend general FM and not worrying too much about scopes. Or you may find you really want bigger time procedures like scopes/ERCPs or cardiac caths, in which case unfortunately you're likely stuck with doing IM-->fellowship.

I had no idea FM could do hemorrhoid removals. Is this under general in an OR ? Only time will tell I suppose. Something tells me I will really love hospital med and I may end up going the hospitalist route where I feel like doing procedures will be common place.

are most hospitalists IM trained? Also, can a FM trained hospitalist treat an admitted Peds pt?

 

[deleted87716]

I had no idea FM could do hemorrhoid removals. Is this under general in an OR ?

Unlikely. He probably means enucleating thrombosed external hemorrhoids. You can do that in your office. I try not to, though.

 

[VA Hopeful Dr]

I had no idea FM could do hemorrhoid removals. Is this under general in an OR ? Only time will tell I suppose. Something tells me I will really love hospital med and I may end up going the hospitalist route where I feel like doing procedures will be common place.

are most hospitalists IM trained? Also, can a FM trained hospitalist treat an admitted Peds pt?

Majority of hospitalists are IM but there's a fair number of FM ones out there.

In theory you can admit peds, but in practice outside of rural areas its pretty rare.

 

[cabinbuilder]

Reality check: I trained to do colonoscopies in residency with hopes of offering that skill in rural practice. I have never done a colonscopy outside of residency and here is why:....

1. Politics and be able to get hospital privileges to do the scopes.
2. Having the staff available to help you do them - not likely in rural setting
3. Having the ability to do anesthesia to do the scopes - no likely in a rural setting if there is no surgeon there.
4. How close you have a general surgeon to your practice in the event of a perforation and urgent repair AND having a surgeon who agrees to back you.
5. No GI's in area to object AND you have someone local who does them who can proctor you for the first 10-15 generally deemed by the hospital.

We had one residency doctor in Texas who did scopes. He learned in Africa doing missions and had 100's of procedures so had the experience.

The only other place I have seen non-GI do scopes is in Alaska and Montana where there really aren't any GI doctors, lots of back up, and surgeons who are in the same area who can help with perforation.

 

[Metamorphosis.DO]

Reality check: I trained to do colonoscopies in residency with hopes of offering that skill in rural practice. I have never done a colonscopy outside of residency and here is why:....

1. Politics and be able to get hospital privileges to do the scopes.
2. Having the staff available to help you do them - not likely in rural setting
3. Having the ability to do anesthesia to do the scopes - no likely in a rural setting if there is no surgeon there.
4. How close you have a general surgeon to your practice in the event of a perforation and urgent repair AND having a surgeon who agrees to back you.
5. No GI's in area to object AND you have someone local who does them who can proctor you for the first 10-15 generally deemed by the hospital.

We had one residency doctor in Texas who did scopes. He learned in Africa doing missions and had 100's of procedures so had the experience.

The only other place I have seen non-GI do scopes is in Alaska and Montana where there really aren't any GI doctors, lots of back up, and surgeons who are in the same area who can help with perforation.

That’s interesting. Where do you practice?

I did my undergrad in Idaho (small town of 28,000) where my family doc did 2-3 colonoscopies a month. A Buddy of mine told me his father (also FM) in a town of 62,000 nearby does 1-sometimes 2 a week.

I actually shadowed my FM doc during one. He does them in office in a procedure room.
I guess this is why I was under the impression it was possible. Maybe I’d have to go practice in Idaho! 😆

 

[manotter]

I am family medicine and do colonoscopies a few times a month. I would say that things are possible if you want to put the effort forth. There is a family medicine group, that I am apart of, that tries to advocate for this :

About Us

As said above, there is still a long journey from now to then, and I hope you enjoy the journey!

 

[Metamorphosis.DO]

I am family medicine and do colonoscopies a few times a month. I would say that things are possible if you want to put the effort forth. There is a family medicine group, that I am apart of, that tries to advocate for this :

About Us

As said above, there is still a long journey from now to then, and I hope you enjoy the journey!

Thank you so much for sharing this. Where did you learn to do them? Mostly in residency or after?

 

[manotter]

My residency trained those who were interested. We did a full scope approach, so OB, inpatient, outpatient and procedures. Since residency I have been in a traditional medicine practice doing OB, adult inpatient, outpatient and various procedures. As always, pick what you want to do and decide how much it is worth it for you to do.

Specifically, two of my family medicine facaulty did colonoscopies and EGDs. In addition, I would work with the general surgeons who helped get more numbers.

 

[cabinbuilder]

That’s interesting. Where do you practice?

I did my undergrad in Idaho (small town of 28,000) where my family doc did 2-3 colonoscopies a month. A Buddy of mine told me his father (also FM) in a town of 62,000 nearby does 1-sometimes 2 a week.

I actually shadowed my FM doc during one. He does them in office in a procedure room.
I guess this is why I was under the impression it was possible. Maybe I’d have to go practice in Idaho! 😆

I agree that small town Idaho is a whole lot different than the rest of the country. I know who you are talking about, they lectured for ACOFP this year. Their practice definitely is not the norm. Again, you have to get permission to do scopes, you have to be able to do you anesthesia or have someone there, you have to have surgical backup in case you perforate someone. Lots of factors to consider.

 

[cabinbuilder]

That’s interesting. Where do you practice?

I did my undergrad in Idaho (small town of 28,000) where my family doc did 2-3 colonoscopies a month. A Buddy of mine told me his father (also FM) in a town of 62,000 nearby does 1-sometimes 2 a week.

I actually shadowed my FM doc during one. He does them in office in a procedure room.
I guess this is why I was under the impression it was possible. Maybe I’d have to go practice in Idaho! 😆

I started out taking an FM job in Montana out of residency hoping that I could do full scope. That didn't pan out due to lack of back up physicians in case of emergencies. Now I strictly do urgent care in Texas.

 

[Sardonix]

I met an FM doc who does nothing but colonoscopies while I was in medical school.

He looks about like someone you would expect who does nothing but colonoscopies. He was allowed to do so because he had so many under his belt and had been grandfathered in after doing it for like 10yrs prior. Not a normal (or enviable) case.

 

[Metamorphosis.DO]

He looks about like someone you would expect who does nothing but colonoscopies.

I wish I could say I knew what that type of person would look like.. this made me laugh.
No I wouldn’t want to only do it. I just think it would be a very valuable thing to offer to patients to avoid some referring out. I personally dealt with a lot of GI stuff as a kid and so I wanted to learn more. All these comments are helpful.

 

[Skindoc83]

Why would anyone want to get their colonoscopy done by a physician that only does 2-3 a month? I would not feel comfortable offering that to patients.

 

[deleted1025203]

Why would anyone want to get their colonoscopy done by a physician that only does 2-3 a month? I would not feel comfortable offering that to patients.

Well, most people wouldn't know better or don't care.

Also, if you can train an NP to adequately perform a routine screening colonoscopy let's not denigrate FM by saying they cannot.

 

[Skindoc83]

i agree that most patients don’t know better. But I don’t think that’s a good reason to offer a service when there are others in the community that have done it thousands of times and do it more regularly than you. This is not a denigration of FM. Obviously an FM doc could be trained to the same level of efficiency and good detection rates as a gastroenterologist, but that would be by doing the same amount of training as a gastroenterologist. One can make the argument that a poorly done colonoscopy is worse than not doing a colonoscopy, because it creates a false confidence that no pathology exists. I’m not aware of NPs doing colonoscopies and I don’t think mid levels should have autonomy anywhere in medicine. But if they were to receive the same level of training as a gastroenterologist, which is three years and several hundred scopes, I’m amenable to change my mind. In this day and age anything you do creates Liability and I think you will have difficulty defending yourself in court by saying you’re an expert at colonoscopy because you do three a month.

 

[manotter]

i agree that most patients don’t know better. But I don’t think that’s a good reason to offer a service when there are others in the community that have done it thousands of times and do it more regularly than you. This is not a denigration of FM. Obviously an FM doc could be trained to the same level of efficiency and good detection rates as a gastroenterologist, but that would be by doing the same amount of training as a gastroenterologist. One can make the argument that a poorly done colonoscopy is worse than not doing a colonoscopy, because it creates a false confidence that no pathology exists. I’m not aware of NPs doing colonoscopies and I don’t think mid levels should have autonomy anywhere in medicine. But if they were to receive the same level of training as a gastroenterologist, which is three years and several hundred scopes, I’m amenable to change my mind. In this day and age anything you do creates Liability and I think you will have difficulty defending yourself in court by saying you’re an expert at colonoscopy because you do three a month.

I would recommend profiency based medicine, more than numerical based medicine. The person who sees the most patients or does the most procedures, is not necessarily the best at the procedure.

In keeping with the current topic of colonoscopies, there are multiple organizations that define initial profiency (GI, surgery, family medicine). Ultimately, an adequate colonoscopy is determined based on the current procedure and the person doing them. The metrics are the endoscopist's rate of getting to the cecum (greater than 90% of the time), their adenoma detection rate (usually 30%), and how long they spent looking at the colon wall on withdrawl (typically greater than 7 min, but studies suggest greater than 10 min). If an endoscopist meets these metrics, I do not see a problem with them doing colonoscopies.

In my current group, I am one of 4 people doing colonoscopies, and my ADR is the highest, but I only do half as many colonoscopies as my colleagues.

 

[AMEHigh]

i agree that most patients don’t know better. But I don’t think that’s a good reason to offer a service when there are others in the community that have done it thousands of times and do it more regularly than you. This is not a denigration of FM. Obviously an FM doc could be trained to the same level of efficiency and good detection rates as a gastroenterologist, but that would be by doing the same amount of training as a gastroenterologist. One can make the argument that a poorly done colonoscopy is worse than not doing a colonoscopy, because it creates a false confidence that no pathology exists. I’m not aware of NPs doing colonoscopies and I don’t think mid levels should have autonomy anywhere in medicine. But if they were to receive the same level of training as a gastroenterologist, which is three years and several hundred scopes, I’m amenable to change my mind. In this day and age anything you do creates Liability and I think you will have difficulty defending yourself in court by saying you’re an expert at colonoscopy because you do three a month.

Are you a family med doc?
Because we do a lot of things ”here and there" a few times per month but we’re still proficient and good at our jobs. I mean, that’s really the whole profession of family med lol. Not everything needs a specialist. So if someone were competently trained in colonoscopies then I think it’d be a great service to offer. I’m sure there are some data out there in regards to complications with non-GI doctors.

I know for a fact that my patients would trust me over some random GI doctor. Most patients prefer to stick with me then go to a specialist when given the choice and it’s within my scope of practice.

 

[VA Hopeful Dr]

Are you a family med doc?
Because we do a lot of things ”here and there" a few times per month but we’re still proficient and good at our jobs. I mean, that’s really the whole profession of family med lol. Not everything needs a specialist. So if someone were competently trained in colonoscopies then I think it’d be a great service to offer. I’m sure there are some data out there in regards to complications with non-GI doctors.

I know for a fact that my patients would trust me over some random GI doctor. Most patients prefer to stick with me then go to a specialist when given the choice and it’s within my scope of practice.

Speaking to colonoscopy specifically, I think there's some fairly good research that shows there is a minimum number you need to do per year to remain reasonably competent.

That number is around 200.

 

[AMEHigh]

Speaking to colonoscopy specifically, I think there's some fairly good research that shows there is a minimum number you need to do per year to remain reasonably competent.

That number is around 200.

Ahh ok got it.
I thought it was more about how thorough the doctor is (not going to fast) and on average how many polyps they find. This article talks about those concepts: Done Right, Colonoscopy Takes Time, Study Finds (Published 2006)

I wonder if that 200 number is the same for other procedures?

 

[Metamorphosis.DO]

Speaking to colonoscopy specifically, I think there's some fairly good research that shows there is a minimum number you need to do per year to remain reasonably competent.

That number is around 200.

Not being contentious— can you try to dig around to find that source if you have the time? Thanks

 

[Drrrrrr. Celty]

Not being contentious— can you try to dig around to find that source if you have the time? Thanks

I don't know if the number is that high, however surgical literature does link high volume surgeons with substantially better outcomes and less complications afterward.

 

[MedicineZ0Z]

Reality check: I trained to do colonoscopies in residency with hopes of offering that skill in rural practice. I have never done a colonscopy outside of residency and here is why:....

1. Politics and be able to get hospital privileges to do the scopes.
2. Having the staff available to help you do them - not likely in rural setting
3. Having the ability to do anesthesia to do the scopes - no likely in a rural setting if there is no surgeon there.
4. How close you have a general surgeon to your practice in the event of a perforation and urgent repair AND having a surgeon who agrees to back you.
5. No GI's in area to object AND you have someone local who does them who can proctor you for the first 10-15 generally deemed by the hospital.

We had one residency doctor in Texas who did scopes. He learned in Africa doing missions and had 100's of procedures so had the experience.

The only other place I have seen non-GI do scopes is in Alaska and Montana where there really aren't any GI doctors, lots of back up, and surgeons who are in the same area who can help with perforation.

There's more in the midwest and south but I don't much know about their practice patterns.

Do the ones you know do only screening scopes or also diagnostic ones?

 

[MedicineZ0Z]

Why would anyone want to get their colonoscopy done by a physician that only does 2-3 a month? I would not feel comfortable offering that to patients.

Because midlevels are learning to do them now. And this isn't a linear system where you can just say "okay well the NP shouldn't do it either" and they go "oh okay." They will continue to train NPs to do them and they will do them independently in the future. So of course for FM docs, it's best to do them if that's your thing. Otherwise, you step aside and let another role get taken over by midlevels.

 

[Drrrrrr. Celty]

Because midlevels are learning to do them now. And this isn't a linear system where you can just say "okay well the NP shouldn't do it either" and they go "oh okay." They will continue to train NPs to do them and they will do them independently in the future. So of course for FM docs, it's best to do them if that's your thing. Otherwise, you step aside and let another role get taken over by midlevels.

Not gonna lie a CNP whose doing 100 a month versus someone whose doing 2 a month is still a lose lose situation.

I think as with a lot of things non-emergent colon and endoscopies probably could be expanded back to general medicine. But I don't envision that happening.

 

[MedicineZ0Z]

Not gonna lie a CNP whose doing 100 a month versus someone whose doing 2 a month is still a lose lose situation.

I think as with a lot of things non-emergent colon and endoscopies probably could be expanded back to general medicine. But I don't envision that happening.

Not the point.
What I'm saying is that just because you or someone else says so and so shouldn't train to do them, is not going to stop them from doing it. Hence why FM docs have no reason to cut back.