A Peek into Gastroenterology in the Military

Session 125

Dr. Brent Lacey is a gastroenterologist in the military, similar to community practice. Listen for a peek into common diagnoses, GI procedures, and lifestyle.

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[01:35] Interest in GI

During his second year of medical school, Brent found the medicine part of things fascinating. He was so interested in the liver and inflammatory bowel disease.

His father is a gastroenterologist and he knew for sure that when he graduated high school, he didn’t want to be a lawyer nor a doctor.

Once he realized medicine was for him, he thought at least he won’t do internal medicine. Then on his third of medical school, he realized internal medicine was for him. So he decided to do internal medicine but he knew he didn’t want to do GI.

Then he got to residency but it was by far his favorite rotation, so he ultimately did GI. As he said, he found the liver and inflammatory bowel disease to be very interesting. He likes the procedure aspect. He has always liked woodworking since he was a kid. He just wants to be able to work with his hands.

'The opportunity to deliver therapeutics immediately and help people feel better was really gratifying.'Click To Tweet

Another thing he liked was the people in the specialty. Every gastroenterologist he met liked their specialty and they were generally happy and fun to be around. It takes a unique personality to enjoy this kind of specialty. All the gastroenterologists he knows have a pretty twisted sense of humor. You just have to so you can keep up with the people making jokes.

[04:40] Traits that Lead to Being a Good GI Doctor

You have to love being around people. In a lot of the GI diseases, you tend to spend a lot of time with these patients. And sometimes, to the point that you could already become their primary care doctor in the sense that he sees them on a more regular basis.

'You get to know their stories and their families. You become part of the family.'Click To Tweet

He enjoys getting to know their stories and families. He thinks this one of the big things that draw people to GI.

[05:33] Types of Patients

GI has an incredibly variable field. They deal with seven different organs – the esophagus, stomach, small intestine, large intestine, the liver, the pancreas, and the biliary system.

Each one of those things could get sick in a variety of ways such as bleeding, cancer, infections, autoimmune processes, and obstructive processes. So they see a wide variety of patients.

About 20%-30% of his practice is liver such as cirrhosis, autoimmune hepatitis, as well as diseases that nonmedical people have never heard of.

For instance, he sees a lot of young men at the base and there’s a huge population of patients with eosinophilic esophagitis. It’s a disease of young men. He performs 20-25 dilations on the esophagus every month.

Additionally, he sees colon cancer patients as well as those with acute and chronic pancreatitis, small bowel tumors, and a lot of irritable bowel syndrome.

'A third to half of my patients have irritable bowel syndrome.'Click To Tweet

About 50%-60% of his time is spent on doing procedures. A typical civilian gastroenterologist is probably going to do more like 70%.

When he started his third-year rotations, he was trying to decide between medicine and surgery as his top two. And if he wanted to be a surgeon, he knew his life needed to revolve around the O.R. Then he found medicine as a bridge between the medicine-oriented stuff and the procedural side of things. He basically had his feet in both worlds.

[10:11] Typical Day and Percentage of Patients Coming In

Brent breaks his days up into either procedure days and clinic days. For the former, he gets up at 5 am and works out. He goes to the hospital to do all the prep stuff and team huddle at 6:45-7 am. The first patient gets in the room by 7:30 am and they do procedures until they’re done. At the end of the day, they call in some biopsy results back to patients and see inpatients.

'One unique part of my practice being a solo practitioner is I'm on call everyday.'Click To Tweet

On clinic days, it’s typically the same routine, only that he’s substituting clinic for procedures. He takes calls from inpatient wards and goes up to the hospital to see people in the ICU.

About 20% come to him already with a diagnosis and could go as high as 35%. But the vast majority of people he sees are patients coming in with new abdominal pain or new swallowing difficulties. They had a lab drawn for one reason or another and their liver test happened to be a little elevated.

[12:05] Getting the History Right is Critical

There are very few specialties where this is more the reality than GI. There are some specialties where you can do enough tests and just shotgun your way into the diagnosis.

If someone comes to the ER with acute chest pain and you’re trying to rule out coronary ischemia, everybody’s going to get your cardiac markers, an EKG, or a stress test of some kind. Some folks get an echo and some get a cath. That’s what everybody is doing. They’re doing a bunch of tests.

'In GI, if you get the history wrong, you are really in trouble.'Click To Tweet

In GI, let’s say a patient comes in and says they have trouble swallowing. The condition could be esophageal dysphagia, pharyngeal dysphagia, odynophagia, or globus. If you look at the differential diagnoses for those four, there’s almost no overlap. So if you can’t get the history right, you get really down the wrong path.

A common pimping question that orthopods love to hit the medicine guys during rotation is what’s the most commonly missed fracture on any x-ray you might read. It was a trap because the answer is the second fracture on an x-ray. Hence, you have to have a methodical approach to reading x-rays. You don’t see the big tibial fracture and then missed the little malleolar avulsion fracture.

If you don’t take a good careful detailed history, you can end up diagnosing one thing and missing a second. Brent says this could scare people away since there’s no algorithm. You really have to be on your game with every single patient.

[16:33] Taking Calls

During the day, Brenttakes calls from their inpatient team, the ICU, the ER, and all the branch clinics. On any given day, he might get 5-10 calls from various places. Most days are fairly stable. He’d have his procedures in the morning and early afternoon. Then he goes and does hospital rounds afterward and heads home.

In the evenings, he’s on the hook for anything. He has a team that covers his pager for him.

For him, the hardest part of him is that he’s the only guy. There’s a nurse practitioner in the team, but it’s still different when you have a team of other guys who have done the same training as you had.

[19:00] Life Outside of Medicine

Brent still manages to find a good work-life balance. Sometimes, he gets called in but not too often. And when he comes home, he doesn’t have to think about work nor charts he has to read. He does all of that stuff once his kids go to sleep or he’s done hanging out.

Brent usually gets up at 4:30 am and goes off to bed around 10:00-10:30 pm. Basically, he has to sacrifice his sleep. He mentions what his mother told him that you can have it all, you just can’t have it all at the same time.

'You can have it all, you just can't have it all at the same time.'Click To Tweet

That being said, he didn’t want to give up being devoted to taking care of his patients. He didn’t want to give up being devoted to his family when he’s at home with them. So what’s got to give is his “me time.”

[21:03] The Training Path

As with everybody, you do four years of college and four years of medical school. Then you do three years of internal medicine residency and another three years of GI fellowship and it branches after that. He elected to stop after that. Fourteen years after high school is quite plenty.

'There are opportunities to do sub-fellowships after you do regular fellowship in GI.'Click To Tweet

Currently, there are four sub-fellowships in GI to choose from – advanced endoscopy, inflammatory bowel disease, transplant hepatology, and GI motility. Brent had the opportunity to rotate through all those during his fellowship. He enjoyed all of them but none of them enough to do them to exclusion. At the end of his three years of GI fellowship, he just opted to do general GI.

The GI specialty is incredibly competitive now mainly due to the popularity of the field.

In the military, it’s a case of supply and demand. They only allocate 1-2 slots in the Navy per year. There are 15-18 of them in the entire Navy. There’s more in the Army with about 30-35.

In the civilian, the average giant programs may have 5 or 6 fellows per year. Most of the programs have two. With a real supply problem, each of the spots is highly-priced.

[23:40] Working with Primary Care Physicians and Other Specialties

As GI doctors, they spent three years learning all those stuff. Brent wishes to relay to primary care doctors that it’s really important to take a really careful detailed history.

There are so many things going on in a 15- to 20-minute appointment. But really ask those complex questions to save the patient the merry-go-round. They come to the GI doc’s office and then sent back to another clinic because they were in the wrong place.

Being in a self-contained system, they see patients in the same way a community practice physician would. As a structural organization, they function well as an academic medical center does. All the family practice and internal medicine guys are all downstairs from him. So it’s easy for him to get on the phone with one of them. Almost every time, they appreciate the extra touch he does, looking out for them.

He also does a lot of lectures for the residents so he goes through things with them on a regular basis. He does the same with the inpatient team and talks about the case with them and working through doing the history and how to think about the differential.

If you’re in a civilian community, it requires a bit more diligence. You also have to be a little careful because the referring doctors are the lifeblood of your business so reach out to them and be appreciative.

'The referring doctors are the lifeblood of your business.'Click To Tweet

Other specialties he works the closest with include general surgeons, allergists, critical care and emergency medicine.

[28:45] Biggest Myths Around the Field of GI

One of the myths around the GI field is that it’s a procedure-only specialty or a procedure specialty where you just sling scopes and that gives you the answer to everything.

Moreover, the subspecialties are often being referred to as either procedure subspecialties or the cognitive subspecialties. Examples of the latter are allergy, endocrine, neurology, while the former includes cardiology and GI. But GI is a highly cognitive subspecialty.

'GI is a highly, highly cognitive subspecialty.'Click To Tweet

Crohn’s disease and the liver are the reason GI training is three years and not two. A lot of those cognitive subspecialties are two years. They spend a lot of time learning the procedures but there’s a lot of medicine practiced by GI.

[30:16] Longer Time for Training

Without the medicine background, you might be able to get away with just three years. Brent thinks this might take four years.

Brent personally thinks it was so valuable for him to have a full internal medicine residency. He has gotten consulted multiple times about something and he makes a diagnosis that really should have been made by the internal medicine team.

That being said, Brent is in favor of proposals that don’t necessarily increase the length of training but don’t decrease the length of training. The variety, the complexity, and the depth of their understanding of the fields of medicine are doubling every five years.

“The whole point of medical school, residency, and fellowship is to turn your brain into a computer hard drive.”Click To Tweet

We need to spend more time if anything. You need to just be able to randomly access that little fact that you spent three hours memorizing ten years later because it ends up being important. You’re not going to be able to look something like that up.

[33:00] The Most and Least Liked Things

What he likes the most about being a GI doctor is the depth of relationships he gets to develop with his patients.

'It's hard not to come home at the end of the day and just go, I have the coolest job ever!'Click To Tweet

So it’s not all about poop, which is another big misconception. Brent clarifies that he can talk about poop all day long but he hardly ever sees it. They do colonoscopies on clean colons.

On the flip side, what Brent likes the least in fellowship is the biliary side of things. He has gotten to see enough of it that he’s starting to enjoy it more. But didn’t really care for the ERCP procedures and the endoscopic ultrasound procedures.

Other things that he finds challenging as a solo practitioner is being on call all the time as opposed to the field in general. Basically, he spends so much time thinking about how great a job he has and just is having a hard time thinking about what he likes the least.

[36:15] Major Future Changes in the Field

Brent sees major changes in the field of microbiology research, like the gut bacteria. There’s a huge amount of research going into that.

In terms of therapeutics, they’re very close to the ability to do a stool transplant for folks taking a couple of capsules that have a bunch of bacteria in it. So if you’re interested in therapeutics, there’s a lot of opportunities there.

You’re going to see a lot more discussion about the procedure-based fields. Those tend to have higher expenditures and higher costs associated with them and how those are going to get addressed. This could mean some changes for reimbursement coming down the pipe.

There are a lot of unexplored territories. There are very few therapeutics for irritable bowel syndrome and there are 50 million people in the country.

'There are a lot of new biologics coming out down the pipeline for inflammatory bowel disease.'Click To Tweet

[37:50] Final Words of Wisdom

If he had to do it all over again, Brent is absolutely going to do it for sure. He has never stopped loving it. He gets up everyday and he’s excited. Even if there are tiny things that frustrate him, at the end of the day, he still comes home thinking he has a great job.

Finally, Brent wishes to tell students and residents to make sure you try to secure a rotation in GI. You may love the idea of something but you may or may not love the reality of it. If you can be convinced in a two-week or a 30-day rotation that it’s not the specialty for you, you needed to be convinced.

Talk to folks in the field. One of the things that he found very helpful was talking to as many people as he could. He’d ask them what they like the best and worst about their specialty. Polarize the questions that way and it forces people to come up with something specific rather than giving you generic answers.

If you enjoy puzzles, and getting to spend time with patients and enjoy developing relationships that last for years and you end up taking care of the entire family, this is a great field with a lot of opportunities!