Is advanced endoscopy training worth it?
There have been many significant changes in the environment surrounding advanced endoscopy practice. Although there are almost 60 graduating fourth-year fellows, there are usually fewer than 12 employment opportunities at tertiary centers each year based on discussion with current fourth-year fellows and endoscopy directors. The Yale University Medical Center recently received approximately 12 unsolicited applications from qualified applicants for a faculty position in 2012.
Are there too many advanced endoscopy training programs? We hope, somewhat unrealistically, that a practice environment, with adequate volume and ongoing mentorship, will be available for physicians completing fellowships in interventional endoscopy.
Mentorship is important for professional development – endoscopic skill and maturity increase greatly during the first few years after an advanced endoscopy training program; therefore suitable positions need to be available. Additional data should be collected from recent advanced endoscopy fellows on their current practice settings, patient volume, and job satisfaction. Potentially underserved regions also should be identified – this information likely would be of assistance to applicants and gastroenterology societies that are developing training policies.
Potential advanced endoscopy fellows also should consider how this career will affect their lifestyle. Many ERCPs are performed under urgent conditions, during nights and weekends. Interventional endoscopy, although gratifying, can be stressful because of the potential for significant complications.8
Medical centers typically have small groups of interventional endoscopists, resulting in a significant call burden. At the Yale University School of Medicine, for example, three endoscopists are responsible for all the interventional endoscopy procedures, in addition to general gastroenterology responsibilities.
Although interventional endoscopists generally are expected to be available 24 hours/day, 7 days/week, and a large proportion of procedures require urgent scheduling, there often is insufficient infrastructure for support (inadequate access to endoscopes, skilled assistants, and anesthesia providers). Most interventional procedures are performed under anesthesia, but variations in turnaround time and availability of providers (especially after hours and on weekends), and their lack of familiarity with endoscopic sedation, can prolong cases or even lead to cancellation of procedures.
It also is important to appreciate the significant opportunity costs of a career in advanced endoscopy practice. For many practicing gastroenterologists, an equity ownership in an endoscopy center generates a significant proportion of their income and also confers a large measure of security and independence. Most full-time interventional endoscopists have no access to or benefit from this venture.
Based on a survey of 12 of 13 graduates of the Yale University Medical Center advanced endoscopy fellowship program, all believed that the advanced training accelerated their professional development. The most-valued benefits of the additional training included the following: a year to focus on endoscopy, the opportunity to have dedicated training from experts, and the career development fostered through fourth-year fellowship branding. Ninety-two percent of respondents said that an advanced fellowship made them more competitive in applying for jobs, and the same percentage said they would make the same decision again (to proceed with fourth-year advanced endoscopy training).
The value of advanced endoscopy training should not be determined by simply comparing the cost of the lost year of income with future income. The training is valuable in that it provides an opportunity to perform research in advanced endoscopic techniques, to gain leadership skills, and to refine endoscopy skills. Although there are challenges to the practice of advanced endoscopy, many endoscopists are driven by them and have great passion for their work.
Given the complexities of procedures and patients, we recommend an advanced endoscopy fellowship for physicians wanting to dedicate their practice to advanced endoscopy. A dedicated year of advanced endoscopy training at a high-volume center, with access to the practices of several experienced endoscopists committed to training, is invaluable. These procedures and challenges will continue to increase in complexity, so ultimately the journey must be fueled by passion for the field of endoscopy.
References
1. Trindade, A.J., Faulx, A., DiMaio, C.J. Perspectives on the advanced endoscopy fellowship match. Gastrointest Endosc. 2012;75:650-2.
2. Trindale, A.J., Gonzalez, S., Tinsley, A., et al. Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship. Gastrointest Endosc. 2012;76:939-44.
3. Rosenthal, L. Is a fourth year of training necessary to become competent in EUS and ERCP? Notes from the 2008 class of advanced endoscopy fellows. Gastrointest Endosc. 2008;68:1150–2.
4. Wani, S., Hall, M., Keswani, R.N., et al. Variation in aptitude of trainees in endoscopic ultrasonography, based on cumulative sum analysis. Clin Gastroenterol Hepatol. 2014;14:S1542-S3565.
5. Singh, S., Sedlack, R.E., Cook, D.A. Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2014;10:1611-23.
