Navigating a Successful Course Through GI Fellowship: A Year-by-Year Perspective

Abstract

The sense of accomplishment you felt as a resident newly matched into your chosen field of gastroenterology gradually morphs into a combination of excitement, anticipation, and indeed a healthy amount of trepidation, as you inch closer to the start of your fellowship. But fear not. Although fellowship is no doubt a character-building experience, presenting unique challenges, it can be effectively navigated with a deliberate approach. This article is intended to serve as a roadmap to guide you in successfully completing your gastroenterology fellowship.The First YearIn most programs, the first year is allocated to clinical rotations, which often means a daunting number of daily consults. While this is arguably the most challenging year of fellowship, you can successfully confront the demands of the year by acquiring new skills, maximizing your clinical efficiency, becoming an effective consultant, and identifying a clinical focus for the future.Acquiring New SkillsOver the course of the year, you not only will expand your knowledge base regarding management of patients with gastrointestinal and liver diseases, but also will begin to master new procedural skills that will initially feel foreign. Indeed, you may spend your first few days (or weeks) of endoscopy examining the same 20 cm of sigmoid colon, but be patient with yourself and do not be afraid to ask for help. Even your seasoned attendings were there once. Take advantage of endoscopic simulators or “pig labs.” These are available at most programs to orient you to basic endoscope mechanics before your first “live” endoscopic experience. Similarly, references that outline basic diagnostic and therapeutic endoscopic techniques offer a helpful introduction to endoscopic practice.1Cotton P.B. Williams C.B. Practical gastrointestinal endoscopy: the fundamentals.6th ed. Wiley-Blackwell, Chicester, UK2008Crossref Scopus (7) Google ScholarReading clinical guidelines as they apply to your patients is a great way to build your knowledge base during this busy year. These guidelines are readily available on major society websites, including the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), American Society for Gastrointestinal Endoscopy (ASGE), and American Association for the Study of Liver Diseases (AASLD). Similarly, we recommend investing in a respected gastroenterology text such as Sleisenger and Fordtran2Feldman M. Friedman L.S. Brandt L.J. Sleisenger and Fordtran's gastrointestinal and liver disease: pathophysiology, diagnosis, management. 9th ed. Saunders Elsevier, Philadelphia2010Google Scholar or Yamada,3Yamada T. Alpers D.H. Textbook of gastroenterology. 5th ed. Wiley-Blackwell, Oxford, UK2009Google Scholar and devising a strategy for comprehensively reviewing the included material over the course of your fellowship. Regular conference attendance also serves an important role in expanding one's fund of knowledge. But remember, you will have much more time during the following 2 years of fellowship to solidify your clinical knowledge and hone your endoscopic skills.Maximizing EfficiencyEffective time management is essential for success in fellowship, particularly during the first year.4Andrade F.H. Time management in the busy professional environment: take that first step.Gastroenterology. 2013; 145: 36-38Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar There will be days in which you are inundated with consult requests, and will need to multitask to ensure not only that every patient is seen, but also that consults are prioritized based on urgency and need for diagnostic and/or therapeutic intervention. Similarly, effectively managing your outpatient clinic requires a systematic approach.•Master the art of triage. Evaluate patients in need of same-day intervention early in the day, so that endoscopy can be arranged. Identify any barriers to endoscopy, such as need for anesthesia support, presence of coagulopathy, need for transfusion, or consent issues.•Maximize procedural efficiency. Communicate early and often with the endoscopy unit staff to review scheduled procedures for the day and their preferred priority. This should minimize any delays, and will make your day flow more smoothly.•Utilize your team wisely. Embrace your leadership role, and understand that your actions set the tone for your entire team. Maintain a helpful presence, but also set clear expectations. Many attendings will defer to you regarding how and when to conduct consult rounds, so keep organized and never lose sight of the big picture. Allocate consults to your residents, PAs, and other team members based on their experience level, efficiency, and interests. Promote an education-focused environment by emphasizing relevant teaching points and clinical pearls outside of formal attending rounds.•Manage clinic responsibilities. Learn the names and functions of your clinic staff early on, and treat them with respect as essential members of the team. Consult your co-fellows and faculty for tips on how to write notes most efficiently, and how to order relevant tests and procedures. Develop a system to communicate results and respond to patient calls in a timely manner.Effective Consult CommunicationAs the consult fellow, you are often the main point of contact for primary teams in the hospital and therefore are a powerful reflection of your entire division. Although many of us entered subspecialty fellowships to take on more of a consultant role, it is vital to reflect back on when you were a member of a primary team in order to be an effective consultant.5Salerno S.M. Hurst F.P. Halvorson S. et al.Principles of effective consultation: an update for the 21st-century consultant.Arch Intern Med. 2007; 167: 271-275Crossref PubMed Scopus (99) Google Scholar•Strike a collaborative tone. The difference between being known as a hostile or helpful fellow lies in how graciously you receive consult requests and communicate advice.•Embrace your role as educator. As a fellow, you have an important responsibility to educate not only the members of your immediate team, but also other house staff, students, and nurses engaged in the care of patients with gastrointestinal and liver disease. Take this obligation seriously, and recognize your vital role in this process. Emailing your team review articles or primary literature relevant to the management of consult patients can effectively reinforce teaching provided during formal team rounds.•Verbally communicate consult recommendations. This includes informing the consulting team regarding the details and outcomes of a recommended procedure, and conversely if and why you do not feel a requested procedure is necessary.•Close the loop. Make sure all of the primary team's questions are answered before signing off. Communicate a clear follow-up plan (ie, outpatient procedures, clinic follow-up) to both the patient and the primary team.Finding a Clinical FocusAs a first-year fellow, you may frequently be asked about your future plans and direction, often with the pretense that you should have figured it out by now. In contrast, in your few free moments away from the hospital this year, your thoughts have been about spending precious moments with family and friends, and balancing your professional and personal responsibilities. The reality is that the demands of first year do not leave a great deal of time for contemplation about our goals for the future. With that said, it is quite important to reflect on the experiences of the first year as they inform your future direction. Perhaps you entered fellowship determined to be a pancreatologist, but enjoyed hepatology more than expected. Maybe you were bound for a super-fellowship in advanced endoscopy, but are now considering general gastroenterology because of its diversity. Talk to as many faculty and co-fellows as you can during the year, and try to gain some perspective on how their career interests evolved, and what factors informed their decisions. Mentors come in many forms, and often these informal conversations can be pivotal in refining one's goals during fellowship.6Rustgi A.K. Hecht G.A. Mentorship in academic medicine.Gastroenterology. 2011; 141: 789-792Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Although some fellows enter training with a very specific career trajectory and never waver, the interests of many fellows diverge with the increased exposure to the intricacies of GI that occurs during fellowship. Often, through these experiences, a clinical/research ‘niche’ will find you, rather than the other way around.Above all, enjoy the year and embrace your evolution from medicine resident to budding gastroenterologist. As you transition into your second year of fellowship, that sense of accomplishment you felt on Match Day will reemerge, and propel you to take advantage of the many opportunities that await you as an upper level fellow and beyond.The Second YearYou are now a second-year fellow. By now, the emergency department and intensive care unit have you on speed dial and you are a welcomed presence on the wards for your heroism in managing GI bleeding and food impactions. Yet, despite this renown, on day 1 of second year you do not hesitate to pass the reigns to a first-year fellow. At that moment, you acquire something that seemed elusive during the first year of fellowship—time. More specifically, you gain time for electives and/or research. Your success throughout the remainder of fellowship and trajectory into the early part of your career is affected by how wisely you use this time. We recommend focusing on enriching your armamentarium in several key areas—clinical knowledge, mentorship, research/elective pursuits, and career planning.Clinical KnowledgeWith approximately 75 trials and 11 systematic reviews published daily,7Bastian H. Glasziou P. Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?.PLoS Med. 2010; 7: e1000326Crossref PubMed Scopus (684) Google Scholar keeping pace with the growing body of knowledge and investigation in medicine is impractical. However, it is expected by the end of fellowship that you will be proficient in content spanning general gastroenterology, inflammatory bowel disease, hepatology, pancreaticobiliary diseases, functional and motility disorders, women's health, research, and systems-based practice as outlined in the “Gastroenterology Core Curriculum.”8American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association (AGA) Institute, American Society for Gastrointestinal Endoscopy. The gastroenterology core curriculum, 3rd ed. Gastroenterology 2007;132:2012–2018.Google Scholar The second year of fellowship is the optimal time to strengthen your understanding and application of this material. A systematic approach should include the following:•Critically appraise your individual patient encounters. Identify learning points. Read the guidelines and evidence supporting the diagnosis and treatment of the condition(s). Review imaging, endoscopy reports, and pathology specimen slides associated with the case.•Actively participate in clinical case conferences and journal clubs. Engaging in clinical case conferences will reinforce your method of critical appraisal. Journal clubs are opportune settings for reviewing new discoveries in the field and learning study methods, design, and interpretation of results. Moreover, clinical case conference and journal club presentations offer excellent opportunities to perfect teaching skills.•Assess your knowledge base. The Gastroenterology Training Exam is a great tool, but is offered annually. Measure your progress and improvement more frequently with periodic testing via use of text or online-based self-assessment questions such as those offered by the AGA (Digestive Disease Self-Education Program [DDSEP]), ASGE (Gastrointestinal Endoscopy Self-Assessment Program [GESAP]), and ACG (ACG Online Self-Assessment).MentorshipThe value of mentorship during your fellowship training cannot be overstated. Mentorship is your GPS navigation through fellowship and your career, regardless of your desired practice setting. If used correctly, it provides detailed and flexible recommendations on how to arrive at your destination (ie, publication, advanced fellowship, work–life balance), rerouting and emergency assistance (ie, last minute abstract revision, phone calls to potential employers), and a network (ie, connections to other institutions, opportunities, committees).6Rustgi A.K. Hecht G.A. Mentorship in academic medicine.Gastroenterology. 2011; 141: 789-792Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar By now, you have likely identified and/or been assigned a faculty advisor, but consider implementing the following steps during your second year of fellowship:•Identify a faculty mentor in your specific area of interest in your department and consider obtaining one outside of your department or institution.•Set clear objectives and goals within the mentor–mentee relationship.•Make a calendar for regular meetings and deadlines.Research/ElectivesDuring your research or elective months, focus your time on projects that complement your ultimate career objectives. Whether you plan to pursue a career in private practice or academic medicine, consider the following:•Involvement in projects that can be presented at national conferences. Conference presentations represent outstanding networking and employment opportunities.•Subspecialty GI electives. Strongly consider subspecialty elective opportunities both within and outside your institution, especially if you are planning to apply for a subspecialty fellowship in inflammatory bowel disease, hepatology, or advanced endoscopy.•Other specialized training. This can include initiation of formal training such as a Master's of Science in Clinical Investigation or Master's of Public Health program. It can also include training in global health, health policy, education, and other areas of interest.Career PlanningA common theme throughout fellowship (particularly the transition from second to third year) should be career planning. It is the main reason for which you have optimized your clinical knowledge, nurtured your mentee–mentor relationships, and pursued research and/or electives up to this point. It is important to make an informed choice as early as possible. Explore the specifics of these career paths through frank discussions with your program director, faculty mentors, and private practice physicians. Honestly evaluate your passion for medicine and your own abilities. What is important to you? What do you want to accomplish in your career? By the end of second year, the answers should be clear.The Third YearAfter years in training, you are almost an attending. In 1 year, you will make the final decision to escalate care in IBD or remove large polyps. No longer will you need to have notes co-signed or procedures supervised. You'll soon be in charge—a great feeling, but also somewhat terrifying. During this third year, you have a unique opportunity to finalize preparations for your career.Private PracticeIf you decide on a career in private practice, you must now seek out opportunities in a somewhat unfamiliar setting, having been surrounded by an academic environment during your training.•Start the application process early. Review published recommendations,9Nayak R.S. A letter to fellows: transitioning from training into practice in uncertain times.Gastrointest Endosc Clin N Am. 2012; 22: 63-75Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar job listings in journals, and those recruiting emails you used to delete. Enlist the help of your program directors and mentors; their insight and connections are invaluable. Start sending out CVs and setting up interviews right away. Be honest with yourself: What are your needs versus wants in a prospective practice? Ask specific questions of future employers regarding their business model and culture—what challenges do they expect to face in the coming years? What is their long-term vision for you? Trust your instincts, but seek feedback on your impressions from your mentors and advisors. When you receive your final contract, have a lawyer review it. Details such as noncompete clauses are sometimes hidden in legalese and can have important implications.•Perfect clinical efficiency. Ensure that you can see patients and perform procedures thoroughly yet efficiently. Practice writing detailed notes that can be easily reviewed when patients call. Develop strategies to timely inform patients of results. Seek advice from graduates of your institution who have recently started private practice. What would they have done differently during their third year to meet the real-world demands of a private practice environment?AcademiaIf you decide on a career in academia, your program directors and current faculty mentors will now be key for guiding you through the process. Meet with them early and often. Have them review your academic CV and application letter and send these to programs early, even if your desired job is not yet advertised.When contemplating an academic appointment, it is vital to carefully consider the characteristics of your ideal position, specifically its balance of clinical and research time. This will allow you to negotiate much more effectively during your job search and find a position that complements your goals and interests. Although academic centers previously were weighted toward research-predominant positions, there now exist multiple established pathways, including purely clinical, clinical-educator, and physician-scientist tracks, with varying degrees of protected time for non-clinical work (including research, education/teaching, and/or administration).10Todisco A. Souza R.F. Gores G.J. Trains, tracks, and promotion in an academic medical center.Gastroenterology. 2011; 141: 1545-1548Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Hospital-based or academically affiliated group practices are also increasingly common.•Practice for an academic interview. Be prepared to discuss the specifics of your research or area of academic interest. Give practice talks at your home institution. Ask your prospective division chief about the environment to support promotion within your chosen academic track. Seek frank advice from junior attendings that have recently joined that division.•Begin focused preparation. Publish those papers you started earlier in fellowship and develop your writing skills.11El-Serag H.B. Writing and publishing scientific papers.Gastroenterology. 2012; 142: 197-200Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Remember that abstracts are a start, but published peer-reviewed papers are what really count. Critically appraise the further training you need to be a successful researcher such as supplemental graduate coursework in biostatistics, and develop a plan for incorporating this into your third year or as an extension of training if needed. Be aware of early career funding opportunities12Podskalny J.M. NIH early career funding opportunities.Gastroenterology. 2011; 141: 1959-1962Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and start the application process now. Present your work at DDW and other conferences, which offer excellent opportunities to network with colleagues and future collaborators within your research area.•Enhance your teaching skills. Build your education portfolio by teaching and presenting to students, residents, co-fellows, and faculty. Seek out a mentor to discuss strategies for being an effective teacher and communicator, as teaching will comprise a significant portion of your academic career.Advanced FellowshipsFor some, the end of general GI fellowship means embarking on further training. Having chosen an advanced fellowship, the third year is an ideal time to build your credentials as an expert in that field. Join your subspecialty societies (eg, ACG, ASGE, AASLD) and attend regional and national conferences. If not directly performing clinical or basic science research in your area of advanced fellowship, seek out mentors to co-author relevant book chapters, review articles, and meta-analyses. Consider focusing your third year on electives in your subspecialty field to enhance your depth of training.The Road AheadTremendous professional and personal growth occurs during fellowship. Having successfully evolved from internist to competent gastroenterologist, you now possess the clinical knowledge and procedural skills to practice independently in the field. Your co-fellows and faculty colleagues will remain your lifelong advisors and friends. The future is bright! Embrace the possibilities as you embark upon your career in gastroenterology. The sense of accomplishment you felt as a resident newly matched into your chosen field of gastroenterology gradually morphs into a combination of excitement, anticipation, and indeed a healthy amount of trepidation, as you inch closer to the start of your fellowship. But fear not. Although fellowship is no doubt a character-building experience, presenting unique challenges, it can be effectively navigated with a deliberate approach. This article is intended to serve as a roadmap to guide you in successfully completing your gastroenterology fellowship. The First YearIn most programs, the first year is allocated to clinical rotations, which often means a daunting number of daily consults. While this is arguably the most challenging year of fellowship, you can successfully confront the demands of the year by acquiring new skills, maximizing your clinical efficiency, becoming an effective consultant, and identifying a clinical focus for the future.Acquiring New SkillsOver the course of the year, you not only will expand your knowledge base regarding management of patients with gastrointestinal and liver diseases, but also will begin to master new procedural skills that will initially feel foreign. Indeed, you may spend your first few days (or weeks) of endoscopy examining the same 20 cm of sigmoid colon, but be patient with yourself and do not be afraid to ask for help. Even your seasoned attendings were there once. Take advantage of endoscopic simulators or “pig labs.” These are available at most programs to orient you to basic endoscope mechanics before your first “live” endoscopic experience. Similarly, references that outline basic diagnostic and therapeutic endoscopic techniques offer a helpful introduction to endoscopic practice.1Cotton P.B. Williams C.B. Practical gastrointestinal endoscopy: the fundamentals.6th ed. Wiley-Blackwell, Chicester, UK2008Crossref Scopus (7) Google ScholarReading clinical guidelines as they apply to your patients is a great way to build your knowledge base during this busy year. These guidelines are readily available on major society websites, including the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), American Society for Gastrointestinal Endoscopy (ASGE), and American Association for the Study of Liver Diseases (AASLD). Similarly, we recommend investing in a respected gastroenterology text such as Sleisenger and Fordtran2Feldman M. Friedman L.S. Brandt L.J. Sleisenger and Fordtran's gastrointestinal and liver disease: pathophysiology, diagnosis, management. 9th ed. Saunders Elsevier, Philadelphia2010Google Scholar or Yamada,3Yamada T. Alpers D.H. Textbook of gastroenterology. 5th ed. Wiley-Blackwell, Oxford, UK2009Google Scholar and devising a strategy for comprehensively reviewing the included material over the course of your fellowship. Regular conference attendance also serves an important role in expanding one's fund of knowledge. But remember, you will have much more time during the following 2 years of fellowship to solidify your clinical knowledge and hone your endoscopic skills.Maximizing EfficiencyEffective time management is essential for success in fellowship, particularly during the first year.4Andrade F.H. Time management in the busy professional environment: take that first step.Gastroenterology. 2013; 145: 36-38Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar There will be days in which you are inundated with consult requests, and will need to multitask to ensure not only that every patient is seen, but also that consults are prioritized based on urgency and need for diagnostic and/or therapeutic intervention. Similarly, effectively managing your outpatient clinic requires a systematic approach.•Master the art of triage. Evaluate patients in need of same-day intervention early in the day, so that endoscopy can be arranged. Identify any barriers to endoscopy, such as need for anesthesia support, presence of coagulopathy, need for transfusion, or consent issues.•Maximize procedural efficiency. Communicate early and often with the endoscopy unit staff to review scheduled procedures for the day and their preferred priority. This should minimize any delays, and will make your day flow more smoothly.•Utilize your team wisely. Embrace your leadership role, and understand that your actions set the tone for your entire team. Maintain a helpful presence, but also set clear expectations. Many attendings will defer to you regarding how and when to conduct consult rounds, so keep organized and never lose sight of the big picture. Allocate consults to your residents, PAs, and other team members based on their experience level, efficiency, and interests. Promote an education-focused environment by emphasizing relevant teaching points and clinical pearls outside of formal attending rounds.•Manage clinic responsibilities. Learn the names and functions of your clinic staff early on, and treat them with respect as essential members of the team. Consult your co-fellows and faculty for tips on how to write notes most efficiently, and how to order relevant tests and procedures. Develop a system to communicate results and respond to patient calls in a timely manner.Effective Consult CommunicationAs the consult fellow, you are often the main point of contact for primary teams in the hospital and therefore are a powerful reflection of your entire division. Although many of us entered subspecialty fellowships to take on more of a consultant role, it is vital to reflect back on when you were a member of a primary team in order to be an effective consultant.5Salerno S.M. Hurst F.P. Halvorson S. et al.Principles of effective consultation: an update for the 21st-century consultant.Arch Intern Med. 2007; 167: 271-275Crossref PubMed Scopus (99) Google Scholar•Strike a collaborative tone. The difference between being known as a hostile or helpful fellow lies in how graciously you receive consult requests and communicate advice.•Embrace your role as educator. As a fellow, you have an important responsibility to educate not only the members of your immediate team, but also other house staff, students, and nurses engaged in the care of patients with gastrointestinal and liver disease. Take this obligation seriously, and recognize your vital role in this process. Emailing your team review articles or primary literature relevant to the management of consult patients can effectively reinforce teaching provided during formal team rounds.•Verbally communicate consult recommendations. This includes informing the consulting team regarding the details and outcomes of a recommended procedure, and conversely if and why you do not feel a requested procedure is necessary.•Close the loop. Make sure all of the primary team's questions are answered before signing off. Communicate a clear follow-up plan (ie, outpatient procedures, clinic follow-up) to both the patient and the primary team.Finding a Clinical FocusAs a first-year fellow, you may frequently be asked about your future plans and direction, often with the pretense that you should have figured it out by now. In contrast, in your few free moments away from the hospital this year, your thoughts have been about spending precious moments with family and friends, and balancing your professional and personal responsibilities. The reality is that the demands of first year do not leave a great deal of time for contemplation about our goals for the future. With that said, it is quite important to reflect on the experiences of the first year as they inform your future direction. Perhaps you entered fellowship determined to be a pancreatologist, but enjoyed hepatology more than expected. Maybe you were bound for a super-fellowship in advanced endoscopy, but are now considering general gastroenterology because of its diversity. Talk to as many faculty and co-fellows as you can during the year, and try to gain some perspective on how their career interests evolved, and what factors informed their decisions. Mentors come in many forms, and often these informal conversations can be pivotal in refining one's goals during fellowship.6Rustgi A.K. Hecht G.A. Mentorship in academic medicine.Gastroenterology. 2011; 141: 789-792Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Although some fellows enter training with a very specific career trajectory and never waver, the interests of many fellows diverge with the increased exposure to the intricacies of GI that occurs during fellowship. Often, through these experiences, a clinical/research ‘niche’ will find you, rather than the other way around.Above all, enjoy the year and embrace your evolution from medicine resident to budding gastroenterologist. As you transition into your second year of fellowship, that sense of accomplishment you felt on Match Day will reem