GI vs HemeOnc fellowship. Your help appreciated.

[PatNanym]

I am an IMG PGY2 in a community-based hospital in New England. I am looking at doing a fellowship in either GI or HemeOnc. I am more interested in GI, but I'm a little apprehensive hearing the match rates (~15% for IMGs this year?) and am confused as to which to apply to. Is HemeOnc almost as competitive as GI, or is it easier, as an IMG? I would really appreciate any input on this as my career choice depends on the decision I make now. Thanks.

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[bashwell]

I am an IMG PGY2 in a community-based hospital in New England. I am looking at doing a fellowship in either GI or HemeOnc. I am more interested in GI, but I'm a little apprehensive hearing the match rates (~15% for IMGs this year?) and am confused as to which to apply to. Is HemeOnc almost as competitive as GI, or is it easier, as an IMG? I would really appreciate any input on this as my career choice depends on the decision I make now. Thanks.

Heme/onc less competitive for IMGs than GI. But still no guarantees for IMGs. See NRMP for the data.

For example, here are 2017 match rates from NRMP (and "total" includes US MDs, DOs, US IMGs, and IMGs, so the match rates are presumably even lower for IMGs only):

Gastroenterology
-U.S. Grads 319/377 (84.6%)
-Total 493/742 (66.4%)

Hematology and Oncology
-U.S. Grads 287/332 (86.4%)
-Total 544/729 (74.6%)

 

[gutonc]

How about you do the fellowship that will make you happy?

 

[IM2GI]

How about you do the fellowship that will make you happy?

But lets be honest, GI is better.

OP, both will be competitive for an IMG. Your best bet is an in-house fellowship if offered by your program and pick the one you like.

 

[PatNanym]

Thank you for the responses. Appreciate it.

 

[bronx43]

But lets be honest, GI is better.

OP, both will be competitive for an IMG. Your best bet is an in-house fellowship if offered by your program and pick the one you like.

Lol, how exactly is GI better than heme onc? Not everyone likes to scope a**.

I agree that your best bet is to stay in house. If you're a great resident, they will already know this and have more incentive to keep you.

 

[868853]

Heme/Onc. It's the better long-term decision.

Over the course of your career you're going to see the Gastroenterologists stop doing Colonoscopies & EDGs, and their reimbursement will go down. The whole idea that you need a medical degree + residency + fellowship to operate a scope is ridiculous. In the near future the system will, appropriately, employ technicians and GI will interpret the results and make decisions as they should. GI doing their own scopes is like if Radiologists doubled as X-Ray techs, CT techs, MRI tech, etc. It just doesn't make much sense.

Go into GI if you really love the medicine and science behind it. But don't do it for the money. It's not viable long-term.

 

[rd31]

Heme/Onc. It's the better long-term decision.

Over the course of your career you're going to see the Gastroenterologists stop doing Colonoscopies & EDGs, and their reimbursement will go down. The whole idea that you need a medical degree + residency + fellowship to operate a scope is ridiculous. In the near future the system will, appropriately, employ technicians and GI will interpret the results and make decisions as they should. GI doing their own scopes is like if Radiologists doubled as X-Ray techs, CT techs, MRI tech, etc. It just doesn't make much sense.

Go into GI if you really love the medicine and science behind it. But don't do it for the money. It's not viable long-term.

Lol.

 

[IM2GI]

Heme/Onc. It's the better long-term decision.

Over the course of your career you're going to see the Gastroenterologists stop doing Colonoscopies & EDGs, and their reimbursement will go down. The whole idea that you need a medical degree + residency + fellowship to operate a scope is ridiculous. In the near future the system will, appropriately, employ technicians and GI will interpret the results and make decisions as they should. GI doing their own scopes is like if Radiologists doubled as X-Ray techs, CT techs, MRI tech, etc. It just doesn't make much sense.

Go into GI if you really love the medicine and science behind it. But don't do it for the money. It's not viable long-term.

Almost zero chance you are a practicing physician, or are just terribly ignorant. You talk like a PA or NP.

Do you really need 4 years of med school, 3 years of IM, 3 years of heme/onc to basically follow NCCN guidelines? No, but there is so much more to being a high quality physician.

 

[bronx43]

Almost zero chance you are a practicing physician, or are just terribly ignorant. You talk like a PA or NP.

I agree that his/her projections are far fetched, but what part of the overall argument do you have a problem with? I would argue that midlevels can certainly operate a scope with enough training, but that there is no mechanism currently in place to facilitate it. However, I can see this potentially happening if reimbursement rates were cut significantly enough where GI docs are simply not incentivized to perform the routine procedures themselves. If payers concurrently allowed for GI docs to bill for "supervising" scopes, then that may open up the doors for midlevels to assume that role.

But the overall point about procedural reimbursement is salient. Colonoscopy rates were recently cut by Medicare, and will likely continue to get cut. Does this make GI not worth pursuing? No, but if you want to do it for the money, then you should probably think twice.

 

[IM2GI]

I agree that his/her projections are far fetched, but what part of the overall argument do you have a problem with? I would argue that midlevels can certainly operate a scope with enough training, but that there is no mechanism currently in place to facilitate it. However, I can see this potentially happening if reimbursement rates were cut significantly enough where GI docs are simply not incentivized enough to perform the routine procedures themselves. If payers concurrently allowed for GI docs to bill for "supervising" scopes, then that may open up the doors for midlevels to assume that role.

It's attitudes like yours that have ruined anesthesiology. Go read their forum with how happy they are about letting midlevels take over their field. Physicians should stick up for each other regardless of speciality. I have zero interest in "supervising" someone else doing endoscopy. I'm not accepting another persons complication without the scope in my hand.

I know you are anti-GI and think it is a piece of cake, but I promise you a few days in the endo suite would humble you.

 

[bronx43]

It's attitudes like yours that have ruined anesthesiology. Go read their forum with how happy they are about letting midlevels take over their field. Physicians should stick up for each other regardless of speciality. I have zero interest in "supervising" someone else doing endoscopy. I'm not accepting another persons complication without the scope in my hand.

I know you are anti-GI and think it is a piece of cake, but I promise you a few days in the endo suite would humble you.

You need some lessons in reading comprehension.

Please show me where I actually supported supervision of endoscopies. I was merely pointing out that this is a POSSIBLE outcome given certain financial scenarios.

I don't actually think scopes are a piece of cake. I just think it can be taught to a non-physician after a substantial amount of training. In fact, the rise of CRNAs in anesthesiology portend this trend. Again, do I support this trend? No, but I face reality with an open mind.

 

[868853]

Almost zero chance you are a practicing physician, or are just terribly ignorant. You talk like a PA or NP.

Do you really need 4 years of med school, 3 years of IM, 3 years of heme/onc to basically follow NCCN guidelines? No, but there is so much more to being a high quality physician.

I also should have mentioned that this idea wouldn't be popular with GI. I'm all for doctors being well paid, but GI continuing to do all their own scopes just isn't feasible long-term, especially with declining reimbursements.

 

[jhamaican]

You need some lessons in reading comprehension.

Please show me where I actually supported supervision of endoscopies. I was merely pointing out that this is a POSSIBLE outcome given certain financial scenarios.

I don't actually think scopes are a piece of cake. I just think it can be taught to a non-physician after a substantial amount of training. In fact, the rise of CRNAs in anesthesiology portend this trend. Again, do I support this trend? No, but I face reality with an open mind.

Any non-physician can be taught anything after a "substantial amount of training". After all, we were all once non-physicians at some point.

I also should have mentioned that this idea wouldn't be popular with GI. I'm all for doctors being well paid, but GI continuing to do all their own scopes just isn't feasible long-term, especially with declining reimbursements.

You clearly have some sort of vendetta against GI. Your posts are absurd. Are we also going to train non-MD to perform basic surgeries such as chole/appys? Does it take a dermatologist to diagnose the most basic and common skin lesions?

 

[jhamaican]

I agree that his/her projections are far fetched, but what part of the overall argument do you have a problem with? I would argue that midlevels can certainly operate a scope with enough training, but that there is no mechanism currently in place to facilitate it. However, I can see this potentially happening if reimbursement rates were cut significantly enough where GI docs are simply not incentivized to perform the routine procedures themselves. If payers concurrently allowed for GI docs to bill for "supervising" scopes, then that may open up the doors for midlevels to assume that role.

But the overall point about procedural reimbursement is salient. Colonoscopy rates were recently cut by Medicare, and will likely continue to get cut. Does this make GI not worth pursuing? No, but if you want to do it for the money, then you should probably think twice.

Please tell us what else you "can see" occurring in the future. And if you don't mind, please private message me with the next apple/google stock. Until then, your posts are pure speculation and it is clear you have no idea what you are talking about. Spitting doom and gloom on a specialty based on your visions of the future is absurd. People have been saying dermatology will get reimbursement cuts for years. GI reimbursement actually increased slightly in the past couple of years.

 

[bronx43]

Please tell us what else you "can see" occurring in the future. And if you don't mind, please private message me with the next apple/google stock. Until then, your posts are pure speculation and it is clear you have no idea what you are talking about. Spitting doom and gloom on a specialty based on your visions of the future is absurd. People have been saying dermatology will get reimbursement cuts for years. GI reimbursement actually increased slightly in the past couple of years.

The only thing I actually made a call on was how reimbursement rates will go in the future. Do you really think that they will go up or stay the same? If so, I would love to put down some money on this, especially with MACRA already set to wreak havoc by 2019. If you go MIPS (which I suspect most private practices will), then your reimbursements will not track inflation (so already a money loser), and there will be the resulting increase in overhead that practices will have to pay in order to even comply with these metrics. And this isn't even considering the potential black swans on the horizon such as single payer or complete abolition of FFS model.

From the perspective of reimbursement, it'll hit everyone. This isn't a GI, cards, surgery, PCP issue. It's a universal issue. My point with GI is that you guys (assuming you are GI) won't be insulated from this.

 

[bronx43]

Any non-physician can be taught anything after a "substantial amount of training". After all, we were all once non-physicians at some point.

I obviously meant substantial amount of "non-physician" training.

 

[IM2GI]

I obviously meant substantial amount of "non-physician" training.

Teaching someone endoscopy is EXPENSIVE in lost procedure time and potential complications:

The time and financial impact of training fellows in endoscopy. CORI Research Project. Clinical Outcomes Research Initiative. - PubMed - NCBI

RESULTS:
Teaching fellows endoscopy added 2-5 min for EGD, with or without biopsy, and 3-16 min for colonoscopy, with or without biopsy. Calculating the number of procedures/h of endoscopy, the reimbursement loss resulting from using fellows-in-training in a university setting would be half a procedure/h. In Veterans Administration hospitals, training of fellows would lose a full procedure/h. In a model of 1000 procedures each of EGD, EGD with biopsy, colonoscopy, and colonoscopy with biopsy, the reimbursement difference between private practice physicians or academic attending physicians and procedures involving fellows-in-training would be $500,000 to $1,000,000/yr.

CONCLUSIONS:
Fellow involvement prolonged procedure time by 10-37%. Thus, per-hour reimbursement is reduced at teaching institutions, causing financial strain related to these time commitments.

Who is going to teach these "endoscopy techs" to do these procedures? You could teach an auto mechanic how to do an appendectomy if you really wanted to, but whats the point? You could teach a tattoo artist how to do a great heart cath I'm sure, but why would you?

It also is not just the act of getting the colonoscopy done and checking a box, it is performing a high quality exam with a provider with a high adenoma detection rate.

Anyway, it is a silly argument, and disappointing to see another physician not see the value a colleague provides to their patients. There are general surgeons out there doing a day or two of endoscopy a month, and family practice doctors doing so as well. I bet when you go get your first colonoscopy you go find a skilled high volume endoscopist to examine your colon.

 

[bronx43]

Teaching someone endoscopy is EXPENSIVE in lost procedure time and potential complications:

The time and financial impact of training fellows in endoscopy. CORI Research Project. Clinical Outcomes Research Initiative. - PubMed - NCBI

RESULTS:
Teaching fellows endoscopy added 2-5 min for EGD, with or without biopsy, and 3-16 min for colonoscopy, with or without biopsy. Calculating the number of procedures/h of endoscopy, the reimbursement loss resulting from using fellows-in-training in a university setting would be half a procedure/h. In Veterans Administration hospitals, training of fellows would lose a full procedure/h. In a model of 1000 procedures each of EGD, EGD with biopsy, colonoscopy, and colonoscopy with biopsy, the reimbursement difference between private practice physicians or academic attending physicians and procedures involving fellows-in-training would be $500,000 to $1,000,000/yr.

CONCLUSIONS:
Fellow involvement prolonged procedure time by 10-37%. Thus, per-hour reimbursement is reduced at teaching institutions, causing financial strain related to these time commitments.

Who is going to teach these "endoscopy techs" to do these procedures? You could teach an auto mechanic how to do an appendectomy if you really wanted to, but whats the point? You could teach a tattoo artist how to do a great heart cath I'm sure, but why would you?

It also is not just the act of getting the colonoscopy done and checking a box, it is performing a high quality exam with a provider with a high adenoma detection rate.

Anyway, it is a silly argument, and disappointing to see another physician not see the value a colleague provides to their patients. There are general surgeons out there doing a day or two of endoscopy a month, and family practice doctors doing so as well. I bet when you go get your first colonoscopy you go find a skilled high volume endoscopist to examine your colon.

I do see the value of your guys' work. That's not the point of all this. I'm just giving my two cents about payment models, procedures, and how things may look different in a few years time for all of us. I mean, in my specialty, infusions are the big money maker, and I totally expect the government to bring down the hammer soon.

I'm at least glad that you agree you can teach anyone with opposable thumbs the majority of procedures. That was actually my point to begin with. Medical school does not give someone significant value add when it comes to procedural excellence - only practice and repetition does that. And yes, I will find a high volume endoscopist to do my colonoscopy, and if in future that "high volume endoscopist" is someone without 4 years of med school, 3 years of residency, and 3 years of fellowship, then so be it. As long as they have done high volumes. In the UK, there are already nurse endoscopists who perform routine procedures and studies have shown comparable outcomes (keep in mind we're not talking about high risk procedures).

In regards to why would this occur, well, from a societal standpoint, it would curtail resource waste. Dedicating that much time, money, and lost productivity to train an individual to perform a task that can be taught in a fraction of the time and with a fraction of the resources is simply inefficient. In fact, I would take this one step further and say that I think our medical education system is antiquated in general, but that's a different discussion for a different day.

I'm not sure what the purpose of this article is, btw. Obviously there is opportunity cost to teaching someone a procedure in the setting of a FFS payment model. This is just basic logic. However, if you believe that FFS will be forever, and that reimbursement schemes or rates will never change significantly, then so be it. I obviously have no crystal ball, but I wouldn't be so dumb as to bet against change.

 

[868853]

Any non-physician can be taught anything after a "substantial amount of training". After all, we were all once non-physicians at some point.



You clearly have some sort of vendetta against GI. Your posts are absurd. Are we also going to train non-MD to perform basic surgeries such as chole/appys? Does it take a dermatologist to diagnose the most basic and common skin lesions?

Relax, I'm a doctor not a policy maker. I have no vendetta against GI at all. I appreciate the work that all of my medical colleagues do in every field, but I live in the real world and I'm capable of seeing big picture. My post about GI was simply in regard to declining reimbursement, the likelihood of further decline in the future, and how it is not wise to choose the career based on financial motivations. If you want to live in a fantasy world then you should move to Narnia.

 

[CCM-MD]

There's already a few NP colonoscopy "fellowships" out there.

Screening Colonoscopy: A New Frontier for Nurse Practitioners

 

[jhamaican]

Relax, I'm a doctor not a policy maker. I have no vendetta against GI at all. I appreciate the work that all of my medical colleagues do in every field, but I live in the real world and I'm capable of seeing big picture. My post about GI was simply in regard to declining reimbursement, the likelihood of further decline in the future, and how it is not wise to choose the career based on financial motivations. If you want to live in a fantasy world then you should move to Narnia.

You have no idea what the field of GI may or may not be in the future. Pure speculation.

Let me guess, you also try to time the markets?

You posts reek of arrogance, stating that Heme/Onc is a the better choice as if it is fact. "GI isn't viable long-term". LOL

Even if colonoscopies were to fall off, GI has massive upside with new weight loss and other endoscopic procedures.

I also live in the real world and am capable of seeing the big picture. But not arrogant enough to act as enough I can predict what the future may hold.

If you can predict the future, why are you a practicing doctor and not making billions? Then you try to play it off when someone calls you out.

If you want to play Nostradamus perhaps palm reading is a better field for you.

 

[bronx43]

You have no idea what the field of GI may or may not be in the future. Pure speculation.

No s*** it's speculation. Anything and everything we say about the future is speculation. I think people here have enough common sense to understand that. You got one guy saying GI is obviously the better field and another saying heme/onc is. Neither offered truly ground breaking analysis or evidence of prescience, but hey... that's the internet.

Drawing the parallel to "playing Nostradamus" or "timing the market" is just asinine. If your position is that no one should say anything about the future even when the future is somewhat pertinent to the discussion, then we may as well shut half of this forum down.

 

[jhamaican]

No s*** it's speculation. Anything and everything we say about the future is speculation. I think people here have enough common sense to understand that. You got one guy saying GI is obviously the better field and another saying heme/onc is. Neither offered truly ground breaking analysis or evidence of prescience, but hey... that's the internet.

Drawing the parallel to "playing Nostradamus" or "timing the market" is just asinine. If your position is that no one should say anything about the future even when the future is somewhat pertinent to the discussion, then we may as well shut half of this forum down.

The post clearly wasn't directed at you, but clearly it touched a nerve because you felt obligated to jump in so quickly. You are an ignorant tool as well, making claims about NP scoping and the long term feasibility about GI as though it is fact. Anyone can tell from your posts that you have never even touched a scope in your life.

I am all for talking about what the future may hold. That is what this forum is for. But lets make clear its pure speculation.

People love to pile onto GI, acting as if the field is dead when in reality it is one of the most sought after fellowships for a reason. This is just fact. The statistics don't lie.

It is pathetic how people love to hate on derm/GI/Rad Onc etc.., wringing their hands gleefully at the thought of these specialties downfall.

When in reality, most of the haters never had a chance at these specialties to begin with and would gladly trade for them if they could. Although they will vehemently deny this through the anonymity of the internet.

Let us take DrSLR for example: He clearly has some kind of bizarre obsession with GI. He joined this forum less than 2 weeks ago. The few posts that he has are either about how heme/onc is the best or GI sucks. Seemingly, he joined simply to vent about GI on an online forum. Looking at his posting history he recently graduated from some low level community IM program. Good luck trying to match GI from there. In summary, we have an individual who loves to hate on a field he never had a chance at. Probably explains a lot.

I only spend the time to refute the no life haters on SDN because of some poor soul may read this forum/thread and may make an uninformed career decision based on ignorant posts.

SDN is chock full of losers, they need to be called out. Sad!

 

[bronx43]

The post clearly wasn't directed at you, but clearly it touched a nerve because you felt obligated to jump in so quickly. You are an ignorant tool as well, making claims about NP scoping and the long term feasibility about GI as though it is fact. Anyone can tell from your posts that you have never even touched a scope in your life.

I am all for talking about what the future may hold. That is what this forum is for. But lets make clear its pure speculation.

People love to pile onto GI, acting as if the field is dead when in reality it is one of the most sought after fellowships for a reason. This is just fact. The statistics don't lie.

It is pathetic how people love to hate on derm/GI/Rad Onc etc.., wringing their hands gleefully at the thought of these specialties downfall.

When in reality, most of the haters never had a chance at these specialties to begin with and would gladly trade for them if they could. Although they will vehemently deny this through the anonymity of the internet.

Let us take DrSLR for example: He clearly has some kind of bizarre obsession with GI. He joined this forum less than 2 weeks ago. The few posts that he has are either about how heme/onc is the best or GI sucks. Seemingly, he joined simply to vent about GI on an online forum. Looking at his posting history he recently graduated from some low level community IM program. Good luck trying to match GI from there. In summary, we have an individual who loves to hate on a field he never had a chance at. Probably explains a lot.

I only spend the time to refute the no life haters on SDN because of some poor soul may read this forum/thread and may make an uninformed career decision based on ignorant posts.

SDN is chock full of losers, they need to be called out. Sad!

Lol, you're a total ******. Ok, I'm done here. You haven't exactly put out a single rational thought other than screaming about speculation, or making ad hominems attacks. You go ahead and enjoy GI. I am glad that you like it.

 

[IM2GI]

You got one guy saying GI is obviously the better field and another saying heme/onc is.

To be clear, I was definitely being sarcastic to @gutonc

I'm sure he is much happier doing oncology than GI, as I am doing GI. That's the wonderful thing about picking your own specialty.

Meanwhile this thread has really taken a turn towards nonsense.

 

[Gastrapathy]

There is more discussion of nurse endoscopists on SDN than there are procedures performed by nurses.

GI's future seems to generate a passion and certitude amongst some on this forum for reasons that they will have to find for themselves. The decline of procedural specialties is predicted year after year. It was stated as fact when I was a med stud 2 decades ago. Somehow, we are still here with an ever expanding role.

So, OP and others, if you like our field, don't worry. As for choosing between GI and Onc, I can't help you. They are so different that it's hard to compare.

 

[bronx43]

GI's future seems to generate a passion and certitude amongst some on this forum for reasons that they will have to find for themselves. The decline of procedural specialties is predicted year after year. It was stated as fact when I was a med stud 2 decades ago. Somehow, we are still here with an ever expanding role.

I also recall the same talk about the downfall of proceduralists, and for the most part it hasn't come to fruition. However, this isn't to say that it hasn't happened at all. It simply hasn't happened across the board. Many of the pain medicine procedures, joint injections, and ultrasound reimbursements have gotten gutted in the past 5 years. Imaging, ophthalmology and a few other surgical subspecialties have seen various amounts of cuts. Now, all these docs are having to make up in volume what was lost in each payment. It's hard to say what the future holds, but my plan and recommendation is to get it while the getting is good. Don't always assume the gravy train will keep rolling, because if/when it stops, it ain't coming back.

 

[PlutoBoy]

And if you don't mind, please private message me with the next apple/google stock.

$NVDA. Carry on.

 

[gutonc]

To be clear, I was definitely being sarcastic to @gutonc

I'm sure he is much happier doing oncology than GI, as I am doing GI. That's the wonderful thing about picking your own specialty.

Meanwhile this thread has really taken a turn towards nonsense.

Yes, it most certainly has.

Closing.