The New Gastroenterologist

The path to becoming an esophagologist


 


Esophagology was a term coined in 1948 to describe a medical specialty devoted to the study of the anatomy, physiology, and pathology of the esophagus. The term was born out of increased interest and evolution in esophagology and supported by development in esophagoscopy.1 While still rooted in these basic tenets, the landscape of esophagology is dramatically different in 2020. The last decade alone has seen unprecedented technological advances in esophagology, from the transformation of line tracings to high-resolution esophageal pressure topography to more recent innovations such as the functional lumen imaging probe. Successful therapeutic developments have increased opportunities for effective and less invasive treatment approaches for achalasia and gastroesophageal reflux disease (GERD). With changing concepts in esophageal diseases such as eosinophilic esophagitis, successful management now incorporates findings from recent discoveries that have revolutionized care pathways. Esophagology is an evolving, dynamic subspecialty of gastroenterology, and esophagologists require comprehensive and unique training during gastroenterology fellowship and beyond (see Figure 1).

A career in esophagology

Figure 1

Optimizing esophagology training during fellowship

First, and most importantly, an esophagologist must have a foundation in the basic principles of esophageal anatomy, physiology, and pathology (see Figure 2). While newer digital learning resources exist, tried and true book-based resources – text books, chapters, and reviews – related to esophageal mechanics, the interplay between muscle function and neurogenics, and factors associated with nociception, remain the optimal learning strategy.

Once equipped with a foundation in esophageal physiology, one can readily engage with esophageal technologies, as there exists a vast array of testing to assess esophageal function. A comprehensive understanding of each, including device configuration, clinical protocol, and data storage, promotes a depth of knowledge every esophagologist should develop. Aspiring esophagologists should take time to observe and perform procedures in their motility labs, particularly esophageal high-resolution manometry and ambulatory reflux monitoring studies. If afforded the opportunity through a research study or a clinical indication, esophagologists should also undergo the tests themselves. Empathy regarding the discomfort and tolerability of motility tests, which are notoriously challenging for patients, can promote rapport and trust with patients, increase patient satisfaction, and enhance one’s own understanding of resource utilization and safety.

Perhaps most critical to becoming an esophagologist, is acquiring sufficient competency in interpretation of esophageal studies. Prior research highlights the limitations in achieving competency when trainees adhere to the minimum case volume of studies recommended by the GI core curriculum.2,3 With the bar set higher for the burgeoning esophagologist, one must not only practice with a higher case volume, but also engage in competency-based assessments and performance feedback.4 Trainees should start by reviewing tracings for their own patients. Preliminary interpretation of pending studies and review with a mentor before the final sign-off, participation in research that requires study, or even teaching co-trainees basic tenets of motility are other creative approaches to learning. Esophagologists will be expected to know how to navigate the software to access studies, manually review tracings, and generate reports. Trainees should refer to the multitude of societal guidelines and classification scheme recommendations available when developing competency in diagnostic impression.5

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