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Tuesday, January 27, 2015

Whatever got you into this specialty, anyway, doc?

Whenever I am asked this question, I can't help but think of the punch line to a joke that was once supposed to be funny but would now be considered beyond the pale in all respects, so I won't repeat it. The punch line is: “Just lucky, I guess.” That's the short answer to why we gastroenterologists work in our field. Despite the distasteful aspect of human waste and the perverse nature of inserting rubber tubes where the Good Lord never intended, there are many reasons my colleagues and I work in a specialty where our slogan might be “Your business is my business”. And speaking of medical specialists, for the information of the jokesters among my 2 or 3 readers, we gastroenterologists are not referred to as proctologists. That's a branch of surgery.

I myself find it surprising that anyone would wonder why I chose my specialty when most people themselves have such a keen interest in such matters. As a rule, people I encounter, upon learning what I do for a living, have questions. Even complete strangers in public places have on occasion immediately shared their digestive problems in embarrassing detail. (One time when the GI professional convention was in town, a ticket-taker at the movies spotted my badge and inquired about his flatulence while my wife and the rest of the queue were kept waiting.) I once thought to try to fend off potential requests for medical advice at cocktail parties by misrepresenting my specialty: if asked what I did for a living, I would reply in a somewhat ominous tone, “I'm in waste management.” I soon gave up that dodge when I discovered that the few people I fooled into thinking I operated a garbage hauling business were even more interested in that business's—undeserved, of course—reputation as mobsters than they were in doctors.

Now, for a few answers …

Above all, I love to eat. Remember that the upper GI tract is half my bailiwick. There is something inherently fascinating about even the fact that we creatures are capable of ingesting and digesting food substances, not to mention what becomes of them. The whole process is nothing short of miraculous! Spinning flax into gold is the stuff of fairy tales, but turning a perfectly good meal into, well, you know what, is something only we living beings can do.

Moreover, eating is a particular interest for my fellow gastroenterologists in general, as best I can tell from our meetings. I would submit to you that our specialty has more and better quality dinner meetings than any other. The whole digestive process is so fascinating that I recently devoured with relish a book about the GI tract aimed at lay people, ”Gulp,” by Mary Roach, and enjoyed every page, even though I knew most of the stories therein. I highly commend it; the digressions and the droll reportage are worth the trip.

As for the distasteful material I have to work with, remember that there are other specialties whose stock in trade I regard as far less delicate. Pulmonology, for example: I would rather deal with a bucket full of stool than a bucket full of phlegm any day. Granted, the urine that my friends the kidney specialists work with is fairly sterile, but so is nephrology as a specialty, in my opinion. And while pathologists nowadays spend the bulk of their time looking at slides with lots of pretty colors, they still have to slice up dead bodies or cut up smelly organs in buckets of formaldehyde. And anyway, for the most part, by the time I come to routinely examine your colon, it is essentially as clean as the inside of your mouth.

But I don't mean to be flip. I will next offer some serious answers to what is a legitimate question, “Why do you enjoy practicing gastroenterology?”

Firstly, most of the people who come for me for help can truly be helped. While cure is only an occasional outcome in medicine, relief of symptoms is a common and attainable goal, and reassurance is almost always possible. (I am paraphrasing a mission statement that was proposed centuries ago by a great physician.) As I see it, of all the medical specialties, with the exception of infectious diseases, ours offers the greatest chance to achieve positive results and even cures. In my own professional lifetime, I have seen stomach ulcers practically vanishing from among the diseases we regularly encounter. We are on the path to wipe out colon cancer. And there is even reason to hope that we will someday find the cause and cure for the most common, least serious, but extremely distressing ailment among GI diagnoses, irritable bowel syndrome!

Second, the converse of the previous claim is the following one: only in minority of cases do we have to deal with the weighty matters of life and death. Of course, it is painful to inform a patient that she has colon cancer or pancreatic cancer. But that task is fortunately infrequent, and when it must be done, it can at least be done in the most supportive possible manner. I am happy I don't have the daily task of the trauma surgeon that comes after an exhausting marathon of trying to patch together a human being: presenting the prognosis to one or more distraught loved ones. Nor do I relish the life of the obstetrician, whose practice usually leads to the joy of a healthy human being arriving in the world, but occasionally, tragically does not.

And third, speaking of OB-GYN and surgery, my hours are definitely more predictable than in those specialties I just mentioned. Of course the hours are long, but these days the number of patients in need of emergency procedures is diminishing. Gastrointestinal hemorrhages are rarely in need of middle-of-the-night endoscopy at my small community hospital. The biggest threat to my sleep is actually the seemingly innocuous piece of steak or sausage that becomes lodged in some poor soul's esophagus, usually during dinner. That's the call from the emergency room that I welcome least, because there is no putting off what we refer to as a “foreign body” stuck in the esophagus.

Fourth, we gastroenterologists get to treat the greatest number of different organs in the human body, although the endocrinologists come in a close second. Of course, oncologists and infectious disease specialists might argue that their disciplines treat every organ in the body, since none are immune to malignancies or infection. But with all due respect, their acquaintance is only passing and superficial. After all, what does the oncologist really know about the life of the stomach that she has cured of cancer? No more than the firefighter knows of the life of the citizen carried from a burning building. In any case, we do manage to avoid boredom in our specialty by treating everything along the pipe that runs from mouth to anus as well as a few side branches such as the liver, gallbladder and pancreas. My first patient of an afternoon in the office might be complaining of trouble swallowing and the next one of difficulty defecating. I pity the poor pulmonologist or cardiologist, with only one organ to claim for their own.

Next comes the matter of how we gastroenterologists spend our workdays. We get to know our patients. I love meeting people and getting to know them as people in the course of diagnosing and treating them. As a gastro doc, I have learned things about people I would never have in any other profession. Of course, the price I pay is having to hear on a regular basis certain intimate descriptions of things that I would just as soon not discuss over dinner. Even in that, there can be some humor. But overall, the role of the gastroenterologist is as close to that of a psychiatrist as any other specialty. Addressing the ”psychosocial” aspects of illness (as they are referred to) can be at times depressing but at times rewarding. I have learned to put people at ease in a wide range of ages, social classes, nationalities and personalities, and they, in turn, have welcomed me into their worlds. (I will concede, though, that there is another specialty that demands an intimate relationship between doctor and patient, namely, oncology, and I suspect this accounts for some of the motivation that keeps my esteemed colleagues doing what they do.)

But sometimes I get weary of hearing about the woes of the world, the worries of the well and the suffering of the ill. That's when it's time to walk down the hall to a place where I don't have to listen to people endlessly bemoan their problems, or act as though they can expect miracle cures, or return and inform me they have failed to do anything I have asked of them. It's called the “endoscopy suite”. There, I can confine even the most tedious of such conversations to the few minutes before we sedate the patient and after they wake up when I brief them before they leave. Tough conversations can be postponed until the biopsy comes back, and even the neediest characters understand when I tell them that I have to see to my next patient who is already “on the table”. And while each patient is “under,” I get to play my favorite music and listen to the gossip of the nurses and assistants while I do what is, thankfully, a routine set of tasks. Lest you worry that as a patient, your doctor is distracted, it is quite the opposite. Sometimes it is routine enough to be “mindless” in the Zen sort of way that driving in Manhattan traffic is for me; I can become so focused on the task that I forget all else. At other times, it is challenge to decide what best to do and how best to do it. Either way, it's a welcome change from the office.

Which brings me to a related attraction of doing GI, which I share to a great extent with surgeons: I get to work with my hands. There is something just plain satisfying about seeing the work of our hands. Even since I was a child, I enjoyed playing with tinker toys, then erector sets, then balsa wood airplanes and then ham radio equipment. Even recently, one of my greatest pastimes has been going to my workshop and putting together a tube guitar amplifier. As you can imagine, it is no small source of pride having cauterized a hemorrhaging ulcer or having removed without hemorrhage a large potentially cancer-causing polyp. And these are just a few of the procedures we general gastroenterologists do. Nowadays, the hotshots in my specialty are actually doing surgery in the abdomen by deliberately making a hole in the stomach with the scope and operating through it and then closing the hole! And all of this work we do is performed by working the controls of a scope and watching a video screen. It's not as much fun as playing a video game, because you can't just reset and start over if you “die,” but you get used to the high stakes involved early in your training, so it's still a rewarding way to spend a morning.

And finally, the intellectual aspect of diagnosing and treating GI problems is an enduring challenge that will not depart from me even if colonoscopy becomes an obsolete test or my hands become too weak to hold an endoscope. The challenge of solving a puzzle, and one that has direct meaning for the person sitting in front of me, remains one of the things that brings me back to work each day. Other doctors do the same thing in their own branch of medicine, but I like to think that I am using my brain so that others can make the most satisfying use of some of their most treasured bodily functions, or at least, some of my favorites. I believe it was Mark Twain who said that of the human needs, one of the most overrated is sex, and one of the most underrated is … well, you know.

So now that you know how I chose my specialty, I plan to share with you in a future discussion, the not-so-secret ways in which I have been able to avoid thus far a doctor's biggest professional hazard: “physician burn-out.” Stay tuned.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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