Gastroenterology Fellowship Training in the 21st Century
Article Outline
Gastroenterology fellowship training is currently under considerable scrutiny by the American Gastroenterological Association (AGA). Some of this interest stems from potential threats to screening colonoscopy, which could alter the nature of the profession,1 as well as recent proposals that hepatology should consider separating from gastroenterology to become a distinct subspecialty of internal medicine.2 However, this latter proposal, although perhaps not the ideal solution and thus unlikely to succeed, reflects a number of fundamental problems with the current nature and configuration of fellowship training in gastroenterology. Over the past year, several recent meetings have been held on this topic by the AGA (and the American Association for the Study of Liver Diseases), including a recent AGA Future Trends Consensus (FTC) Conference in March of 2008. Although a more detailed analysis of the AGA FTC conference will be communicated later this year, I thought I would provide some background on the current challenges that our specialty faces with respect to fellowship training.
In many ways, this is the best of times for gastroenterology fellowship training. GI remains one of the most popular specialties in internal medicine, with many excellent applicants for every open position. For the last several years, there have been many highly qualified internal medicine graduates who were unable to even land a fellowship spot on their initial application. The applicant pool is so deep that many programs could indeed expand the size of their fellowship by several positions without a significant drop in quality, although for economic reasons such an expansion is highly unlikely. In addition, the Match has restored order and predictability to the process of filling GI fellowship slots, and the 2008 Match (the 3rd year for the rejuvenated Match) resulted in 97% of positions filled. Gastroenterology as a specialty continues to develop, with technological advances providing ever more tools for luminal interventions, and remains valued by society, academic medical centers, and third-party payers.
However, gastroenterology will likely struggle in the future to attract the best and the brightest if internal medicine continues to fare poorly in comparison with other specialties such as dermatology, orthopedic surgery, plastic surgery, and radiation oncology, which are attracting a growing share of top medical students. The GI fellowship itself has become more stressful and demanding. Gastroenterology has become one of the busiest consult services in the hospital and is now dominated by endoscopy for GI bleeding and PEG placements to the point that rounds are hurried with little time for discussions of physiology or pathophysiology. The combination of heavy clinical service and expanding American College of Graduate Medical Education (ACGME) requirements for training has reduced the time and focus for academic pursuits at many programs. This has been confirmed by recent surveys demonstrating that fellows in gastroenterology (and cardiology) spent less time in research than fellows in other medicine subspecialties.3
The assumption has been that a very broad training program in GI, locked into place by ACGME guidelines and codified by American Board of Internal Medicine requirements, is the best approach for ensuring the future of gastroenterology as a specialty. But although fellowship training was lengthened to 3 years and clinical requirements to 18 months, the opportunities for subspecialization and for rigorous academic pursuits have diminished. Many gastroenterology trainees who want to pursue advanced interventional endoscopy, inflammatory bowel disease (IBD), or transplant hepatology, have discovered that a 4th year of training is mandatory. The need for a total of 7 years of training postgraduation must be recognized to be somewhat of a deterrent to many young trainees with families and debt who would otherwise pursue training in these disciplines. Although the shortage of transplant hepatologists and IBD specialists is due partly to the lure of colonoscopy, the rigidity and somewhat skewed focus of gastroenterology training is no doubt part of the reason that only a minority of graduates of GI fellowship programs choose to focus their careers on these areas of medical practice. The overemphasis of gastroenterology training programs on general GI practice might be viewed by some as a strength, although it has been argued by others that most training programs actually do a poor job preparing trainees for community practice.4 Fellows are still trained primarily based on an inpatient model, seeing consults in an acute care setting, and office-based outpatient gastroenterology, which has a very different pace and requires more rapid decision making, remains a small part of their experience.
As we look forward into the 21st century, we need to consider how best to train our fellows so that they will be prepared for future decades, when technological innovations will continue to advance, web-based learning will become the norm, genomics finally makes its way to the patient bedside, and many more sub-subspecialties emerge from the practice of gastroenterology and hepatology. Other subspecialties, such as cardiology and oncology, are beginning to address the same issues, and we should reflect on the lessons learned from their experiences. Perhaps consideration could also be given to the balance between time spent in internal medicine versus subspecialty training, and shortening the former may provide more options for the latter. One hopes that postgraduate training as a whole becomes more streamlined and that GI fellowship programs can become more flexible, separate clinical service from training, and somehow adapt to allow more personalized training to better fit the needs of trainees.
References
- . Will screening colonoscopy disappear and transform gastroenterology practice? (Threats to clinical practice and recommendations to reduce their impact: report of a consensus conference conducted by the AGA Institute Future Trends Committee). Gastroenterology. 2006;131:1287–1312
- . Hepatology: small steps forward. Gastroenterology. 2008;134:381
- . Research training in six selected internal medicine fellowship programs. Ann Intern Med. 2000;133:800–807
- . GI Fellowship training—the missing piece. Am J Gastroenterol. 2005;100:1912–1913
The author discloses no conflicts.
PII: S0016-5085(08)01792-7
doi:10.1053/j.gastro.2008.09.060
© 2008 Published by Elsevier Inc.
