What is Pediatric Gastroenterology? We Learn From One Today

Introduction

Dr. Ryan Gray: Specialty Stories Podcast, session number 9.
Whether you’re a premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you will want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Welcome to the Specialty Stories Podcast, I am your host Dr. Ryan Gray, and in this podcast we share with you exactly what our title says. Specialty Stories. Today I have the honor of interviewing a friend who happened to be in town for a conference, and so I brought her into the studio, and we talked about her specialty. Maureen Leonard- Dr. Leonard is a pediatric gastroenterologist, and she’s going to tell you all about that path.

Meeting a Pediatric Gastroenterologist

Dr. Leonard: My name is Maureen Leonard and I am a pediatric gastroenterologist.

Dr. Ryan Gray: And how long have you been practicing as a pediatric gastroenterologist?

Dr. Leonard: I’ve been practicing for about a year and a half.

Dr. Ryan Gray: And are you in an academic or community-based setting?

Dr. Leonard: I am in an academic setting.

Dr. Ryan Gray: When did you know you wanted to be a pediatric gastroenterologist?

Dr. Leonard: I had an idea that I might want to be one when I was about in fourth year of medical school, but I had a couple of other ideas for what I might be.

Dr. Ryan Gray: What were those?

Dr. Leonard: Well I knew I was definitely going into pediatrics because I really enjoyed pediatrics, and then my other ideas were pediatric GI, pediatric neurology, or pediatric HemOnc.

Dr. Ryan Gray: And how did you narrow down those choices?

Dr. Leonard: I did some electives in all of those things, and pretty soon after doing pediatric neurology I knew that wasn’t for me. And so going into general pediatric training I was going between pediatric GI and pediatric HemOnc.

Dr. Ryan Gray: What traits do you think lead to being a good PDGI doc?

Dr. Leonard: You have to have a sense of humor because you’re going to talk about poops and farts all day, and that’s funny for some people including me and children. You have to- I don’t know like some variety to your day because you’re doing procedures, you’re seeing children, you’re working with parents.

Dr. Ryan Gray: What types of patients do you treat?

Dr. Leonard: So we see kids of all ages and we see kids that we follow for a short time whether that’s because they’re having poor growth, or something like reflux or constipation which we can manage, and treat, and we have them move on. Or we see patients and we follow them for many, many years, and those might be our kids with Celiac Disease, or Inflammatory Bowel Disease. Within pediatric GI you can sort of further sub-specialize into things like liver disease, sometimes someone who really focuses on certain procedures, or general GI. So there’s a lot of opportunities and different patients you can see.

A Day in the Life

Dr. Ryan Gray: Describe a typical day.

Dr. Leonard: Well I have three different days of my week. So a typical day seeing patients is because I’m in an academic center and I focus on patients with Celiac Disease, I have a little bit more time to spend with patients, so that’s anywhere from closer to thirty minutes instead of fifteen which is nice. So I will see- one day a week I see patients every thirty minutes or so. We go over labs, we sort of check in, and it’s sort of a typical day in the office. There’s a day of the week where I do procedures, and so on those days I’m in pretty early, 7:30 or so. At that point I’m either doing endoscopies, or colonoscopies, or both on children, so again that’s an interesting day working with a different group of people- anesthesia, nurses in a procedure room and doing a procedure about every thirty to sixty minutes.

Dr. Ryan Gray: For somebody that isn’t aware of those types of procedures, describe endoscopy, colonoscopy.

Dr. Leonard: Yeah so for kids we put them to sleep, it’s a short procedure. So an endoscopy, typically a child would come in, anesthesia would put them to sleep. I take a tube that looks sort of like a stethoscope but is longer and has a camera on the end, and go down the throat into the esophagus, stomach, small intestine and take biopsies while I’m there. Typically the procedure itself takes about ten minutes, though they’re in and out pretty quick, and they’re out of the procedure area within an hour or two of their visit. For a colonoscopy that takes a bit longer, it can be anywhere between thirty to 45 minutes, and that depends on how well the clean-out went. So we have patients drink stuff so they essentially pee out of the butts as I say to them, and as long as they’re doing that then we have a good view. So colonoscopy would take thirty to 45 minutes, again it’s a slightly bigger scope, and we sort of drive around the colon looking for abnormalities, taking pictures along the way, and as we back out we take tiny pieces of tissue so we take biopsies then.

Taking Call as a Pediatric Gastroenterologist

Dr. Ryan Gray: Do you have to take a lot of call?

Dr. Leonard: At the academic center I’m at, no. So as an attending physician there I’m on call three weeks a year, and that’s 24 hours a day for seven days. We have fellows that take the first call, we have residents that are in the hospital to sort of put in the order. So as an attending physician, no I get second or third call and about 21 days a year.

Dr. Ryan Gray: You mentioned earlier when I asked you about a typical day, you said you have three days. You mentioned seeing patients, procedure days where you’re seeing patients too. What’s that third day for you?

Dr. Leonard: Yeah so three days a week I am doing research. So that means for me it could be anything from having meetings with start-up companies, or industry partners about what we’re doing, and what they’re doing, and how we can collaborate. It’s working on- it’s writing manuscripts, writing grants, working on research whether it’s- I do translational research so that’s clinical and bench research, so there may be experiments going on. So three days a week I’m sort of in a lab, in an office, writing and managing research. And then one day is seeing patients, and then a half a day every other week is doing procedures.

Dr. Ryan Gray: Describe translational a little bit more.

Dr. Leonard: So translational is essentially taking things from the bench to the bedside, or taking things from the bedside to the bench. So using patient samples and trying to understand mechanisms of disease in that way. So really sort of bridging what’s going on in the lab to what’s going on with patients. So all of my research is really based on taking patient samples and trying to find a mechanism of disease based on that.

Achieving Work Life Balance

Dr. Ryan Gray: Do you feel you have good work life balance?

Dr. Leonard: I think it’s hard in research. I think it’s hard just being a doctor to have good work life balance, but in research it can be difficult because there’s always a paper to write, there’s always a grant to write, there’s always reading to be done. So I think this is a great work life balance for me right now because I only have three weeks of call, I have one day a week where my time schedule is really based on patients so if they’re late I’m late, and three days a week I can really make my own schedule. So I think I have a great work life balance right now, but it’s something that I have to constantly keep in check because I could write grants or papers all day every day including the weekends.

Educational Path to Becoming a Pediatric Gastroenterologist

Dr. Ryan Gray: What is the residency path post-graduate training for somebody that wants to enter PDGI?

Dr. Leonard: It’s three years of a general pediatric residency, so you’ve probably heard about that a little but that’s every month is sort of different whether it’s pediatric neurology, or HemOnc, or the general team, emergency room, outpatient. So you get to see a bit of everything there. From there it’s three years of pediatric GI fellowship, and what that entails is one year of- where I was it was one clinical year, so that meant I was on call about six months of the year. There were two of us and we sort of traded off the entire time. And then it was two years of research where you also had about ten weekend calls a year during that time. So I did those two, and then because I wanted to focus on research, I did a Master’s degree in clinical and translational investigation, and I did that my third year of fellowship and my first year as an attending.

Dr. Ryan Gray: Talk about your decision on fellowship choice. How did you choose- or how should someone choose to look at what fellowship programs to apply to? What types of things should they be looking at?

Dr. Leonard: So some of the important things for me were I wanted to find a fellowship that had at least one co-fellow because I know that you can get burnt out pretty quickly, and if you were alone you would have more call than six months a year, and I thought that was not going to be great for my work life balance. So I wanted a place where there was at least two of us. I was interested in doing research for my career when I went into fellowship, and so I knew that really it’s very difficult to get anything done in two years research-wise. Not anything but something really significant, it’s difficult. So I wanted to choose a place where I knew I wanted to stay for awhile. So I grew up in Boston, my family is there so I was hoping to sort of find a place that I would like to stay so that whatever research I started in fellowship would continue. I certainly think looking at sort of the dynamics of the group are important, but that’s something- sometimes I think that’s pediatric specific. You know we like to have fun, be happy, and so we definitely look into like, ‘does this feel like a family?’ So that was something else that I wanted to look into; the support, the mentorship there.

Dr. Ryan Gray: So you did your training at MGH, very research heavy institution. You mentioned the fellowship was three years; one year clinical, two years of research. I’m assuming that not all PDGI fellowships include those two years of research.

Dr. Leonard: Right some are made up a little bit differently. I think overall people try and get a good year and half to two years of research somewhere in there, but those fellowship programs where there’s only one fellow every year, the other two- the fellows that’s a second year and a third year, they’re doing more clinical time in their second and third year because they have to help out that first year fellow who can’t be on for twelve months straight. So in those cases some of those programs might have you’re on for four to six months a year clinically, and that could be pretty much- maybe six months the first year, four months, and then two months or something like that. So some people spread it out a bit more, but I- again I knew I wanted to focus on research, and the other thing that I found, and that people always said, is you really need to protect your time and focus just on research. So if you’re taking two months off, I know when I was working on the bench I tried to plan everything out, and then the day I wanted to do the experiment, the cells weren’t ready. So when you have to go between clinical and research it’s difficult.

Dr. Ryan Gray: So there’s no such thing as like a one year PDGI fellowship with no research? Almost all of them or all of them are research focused as well.

Dr. Leonard: They’re all three years right now. And I know there’s always a discussion about whether that’s appropriate or not, but that’s how it is.

What Makes for a Competitive Applicant

Dr. Ryan Gray: Okay. What do you think makes a competitive applicant to PDGI?

Dr. Leonard: So to be competitive for pediatric GI, I think you need to have at least done a rotation with pediatric GI. That’s helpful so that you can see what we do, but also so that you can form relationships with the pediatric GI department. It’s still a small field, there’s probably 1,000-1,200 pediatric GIs in the United States, so it’s a small field so you want to make friends and get to know your pediatric GI doctors at the institution. We definitely look for people who’ve done research, whether that’s presenting a poster, as a medical student or resident, or publishing a paper. So I think we also look for in residency people that have spent some time doing research either as an elective or on the side, because it’s such an important part of the fellowship, that we want someone who’s interested in that as well.

Dr. Ryan Gray: Is matching competitive?

Dr. Leonard: It’s very competitive, because again you have places that have one or two spots. And say Boston where I was, there are two fellowship programs in the city of Boston, one has two people, one has four to six people depending on the year, so it’s very competitive.

Dr. Ryan Gray: Okay. Is there any bias that you’ve seen among MD versus DO applicants to PDGI?

Dr. Leonard: I would say the majority of applicants are MD. I don’t think that there’s a bias against DO, but we definitely- but I’m not on the selection committee and I know that we don’t interview an equal number by any means.

Dr. Ryan Gray: Okay and that would kind of make sense because just in general terms there are many less DOs.

Dr. Leonard: Right.

Sub-Specializing in the Field

Dr. Ryan Gray: Okay, alright. You talked about it a little bit, but if you could go into it a little bit more in depth, or not at all if there isn’t much more, but the opportunity to sub-specialize as a PDGI. So you finish your three years of PD residency, three years of GI fellowship- or PDGI fellowship. Where do people go after that if they want to specialize further?

Dr. Leonard: Yeah so I think it really depends on where you’re located. So definitely the cities, these major academic centers, people are really moving towards super specializing. So again, if you’ve done your training and you don’t want to stay at the major academic center in the city, then you’ll see general GI. There are additional fellowships for a pediatric gastroenterologist, so you can do a liver transplant fellowship for one year I believe. It’s one or two years. You can do a nutrition fellowship for another one or two years, so some people go forward there. That was another reason that I wanted to sort of stay where I trained, because I began to really focus on a certain super sub-specialty as a fellow, and then I could take that with me as an attending. But there are additional fellowships or a lot of places in the cities right now are sort of asking you to begin to almost brand yourself, or choose your super sub-specialty while you’re training.

Taking the Boards

Dr. Ryan Gray: What do the boards look like?

Dr. Leonard: So you take your general pediatric boards, which are difficult, and then I would say the pediatric GI boards are very difficult as well because again, just like the general pediatric boards, they’re asking about general genetic diseases that you may not see very often. Metabolic diseases that you may not see that often. They’re asking for a really wide range of things, and again we don’t see that wide range as often.

Dr. Ryan Gray: Regular PD boards are one of the lowest- have one of the lowest passing rates as far as I know. Is that correct?

Dr. Leonard: Yes.

Dr. Ryan Gray: Yeah, what is that passing rate? Do you know?

Dr. Leonard: I thought it was between 75% and 80%.

Dr. Ryan Gray: Okay, pretty sure. I’m not sure why it’s so hard.

Dr. Leonard: Well I think it’s a lot- because if you go through, I mean think of every metabolic disorder you can have, every enzyme. I mean there’s so many of those things, and the number of times we see them you can count on one hand. So genetic disorders, metabolic disorders, all of those things make it difficult.

What Dr. Leonard Wishes She Knew Then

Dr. Ryan Gray: Okay. As a PDGI doc, what do you wish you knew going into fellowship that you didn’t know that you know now?

Dr. Leonard: I mean I was pretty prepared for it. I think again, because I was interested in research, I think people should know that depending on where you go there’s going to be a heavy emphasis on research. Two years out of three is a lot. And the clinical stuff, everyone picks up eventually, and you study, and you work on your procedures. But the time that you really determine what kind of pediatric GI doctor you’re going to be; are you going to be a researcher, are you going to be a clinician, are you going to be a motility expert, are you going to be doing liver transplants? That’s all in the second two years, so I think just knowing that you choose pediatric GI, but many people will then go on and really super focus after that.

Working With Other Physicians

Dr. Ryan Gray: What do you wish primary care providers- and so in your case pediatricians, what do you wish pediatricians knew about what you do? How could they help you do your job?

Dr. Leonard: In general I wish that general pediatricians may sort of send screening labs, or for kids with constipation consider starting Miralax before they come see us. I think for kids with reflux they often get started on medications, and that’s okay for the older kids, but I also wish as infants they sent us- they sent infants to us earlier than maybe they do because there’s a lot of infants on acid blockers that don’t need to be on them.

Dr. Ryan Gray: And then your sub-specialty as a Celiac doc, what do you wish pediatricians would know?

Dr. Leonard: I wish they would know that they should not suggest starting a gluten free diet unless the child has been worked up for Celiac Disease completely, and that really includes seeing a pediatric gastroenterologist. I wish they knew how infrequent gluten sensitivity is in children because again, most children do not need to be on a gluten free diet. And I wish they would sometimes give me a call because when we have- we’re always available to try and squeeze people in too, so I don’t like people waiting and wanting to go on a gluten free diet when I can just sort of try and squeeze them in.

Dr. Ryan Gray: What other specialties do you work the closest with?

Dr. Leonard: So we work really closely with pediatric surgery. That’s because oftentimes we might have kids that come in with obstruction and we have to think about where is this coming from, and who should monitor it and manage it? Our kids with Inflammatory Bowel Disease often unfortunately go to surgery, so do our patients with liver disease. So we work quite a bit with pediatric surgery, we work quite a bit with pediatric radiology. Again when we’re assessing our IBD kids with CT scans, or MRIs, or doing different barium swallow studies to look at the esophagus, and things like that. So I would say pediatric surgery, pediatric radiology are the top two that we work with.

Opportunities Outside of Clinical

Dr. Ryan Gray: Are there any areas outside of clinical practice and research for PDGI?

Dr. Leonard: My work is in the Microbiome, and that’s a really hot topic right now, and being located where I am in Boston, there’s a lot of start-ups and sort of pharmaceutical industry partners there that want to be involved in research. So I think as a pediatric gastroenterologist, because you have this training in research, you do have the opportunity to work in industry if that’s something that appeals to you, so I think that’s a great option for people.

Best and Worst of Pediatric Gastroenterology

Dr. Ryan Gray: What do you like the most about being a PDGI doc?

Dr. Leonard: I love the variety in my week. I love having a couple of days where I can focus on research. I love being able to see patients and my procedure days we have a lot of fun talking with the kids, playing music, and hanging out with the anesthesiologists and the nurses. So it’s a lot of fun in that sense, and I really like that a lot of my patients get better so that they can- there are a lot of happy moments in pediatric GI, and a lot of funny moments because a lot of kids don’t want to- or aren’t used to talking about poop and farts, and so we can have a lot of fun with different stool charts like, ‘Does your poop look like a chicken nugget or is it more like soft serve ice cream?’ So that all to me is still hilarious and so my days are pretty fun.

Dr. Ryan Gray: Alright. What do you like the least about being a PDGI doc?

Dr. Leonard: I guess it’s just hard to balance everything as a clinical investigator. It’s hard to balance because I want to be there for my patients all the time and focus on my research. So I would say that, but otherwise the patients are great, procedures are great. It’s fun.

Dr. Ryan Gray: If you had to do it all over again, would you still choose GI as a fellowship?

Dr. Leonard: Absolutely. Nowhere else can I use my tap and fart app.

What the Future Looks Like for Pediatric Gastroenterology

Dr. Ryan Gray: Do you see any major changes coming to the PDGI world whether that’s because of technology, or medications, or whatever?

Dr. Leonard: Yeah, so again one of the major I think shifts in the past probably decade has been towards this super sub-specialty in some centers for pediatric GIs. I think the next thing that’s going to come down the pipeline is probably someday changes in how we do procedures. So there are people looking at certain capsules that are tethered to string, and that may be able to take biopsies or take pictures at such a level that we don’t need biopsies. So I think at some point maybe we’re going to be doing a lot less endoscopies and colonoscopies once that happens. And I think we’re always nervous about- or if you’re interested in research, the funding environment. But again, because there are so many sort of really interesting areas coming down the pipeline in terms of the Microbiome, and precision medicine, there’s a lot of opportunity in research and in industry.

Words of Wisdom

Dr. Ryan Gray: Any last words of wisdom for the premed, medical student, or even resident listening to this that’s interested in PDGI?

Dr. Leonard: I think it’s a great field if you’re interested in sort of having a lot of variety to your week and to your patients. So you get to do procedures, you get to work with a lot of different groups, and you have a nice balance between patients that get better quickly, and patients that you get to follow for a longer time period so it’s fun.

Final Thoughts

Dr. Ryan Gray: Alright that was Dr. Leonard, again pediatric gastroenterology. So very interesting there. Three years pediatric residency, three years of pediatric gastroenterology fellowship which includes multiple years of research. Now Dr. Leonard is not an MD PhD, she is ‘just’ an MD. And a lot of questions come up- I get a lot of questions about doing a lot of research as an MD and not having a PhD. And so Dr. Leonard is showing that you don’t have to have that PhD to do a lot of research in your career. So probably something I’ll have her on the show to talk about at another point- the show meaning the other podcast, The Premed Years, to talk about working as an MD and doing that amount of research to see if the PhD route- if she regrets not having a PhD, or if she’s hindered by not having a PhD. I think it’s an important topic.

So I hope that this episode was good for you. If you’re interested in PD or a sub-specialty of pediatrics, then pediatric gastroenterology might be right up your alley. So hopefully you got something good out of it. If you did, I would love for you to share this with a friend. Go let them know to listen to the Specialty Stories Podcast every week on iTunes, Stitcher, Google Play Music, or wherever you listen to podcasts.

Don’t forget, check us out next week here at the Specialty Stories Podcast.