The First Years after Fellowship: Our Perspective

Fellowship provided a strong focus on clinical training. I was challenged by and learned a great deal from complex patients seeking third and fourth opinions in gastroenterology (if two or three smart gastroenterologists had not been able to fix them, what chance did I have?). Even 60–90min for a new patient encounter sometimes seemed insufficient for an unseasoned gastrointestinal (GI) fellow. Sifting through complex medical history and piecing together extensive prior GI evaluations could be tedious and time consuming. Private practice routinely involves more mundane and less complex “bread and butter” gastroenterology where a 20–30min initial office visit is enough to understand the problem and make an appropriate diagnostic and management decision. Typically, the first stages of GI work-up begin after an initial office consult, as opposed to being a latecomer to their GI evaluation as was often the case in fellowship. Following a basic GI evaluation, many patients see improvement with a proton pump inhibitor (PPI), a low-fermentable oligo-di-monosaccharide and polyols diet, a low-dose tricyclic antidepressant, or even simple reassurance. Occasionally, they do not require follow-up. Our office places status phone calls 2–4weeks after an office visit to make further adjustments or fine-tune the management plan. This frequently suffices to determine whether further follow-up, additional testing, alternate therapeutic agents, or simply a “call if symptoms return or worsen” is needed. Although only a small fraction of the 25–30 outpatient visits per week involve degrees of complexity encountered during fellowship, the training experience laid the groundwork formy comfort with the variation and complexity within the GI spectrum.