So you want to be ... a gastroenterologist

Published: 1 February 2006
By: Professor John Hunter - British Journal of Hospital Medicine

Article published with permission of the British Journal of Hospital Medicine.
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Why be put off by jealous colleagues who make school-boy jokes about bums and bottoms? True, detailed enquiries into bowel habits are necessary for the resolution of many patients’ complaints, but actual faeces play a small part in the life of the well-organized gastroenterologist. Discussions of bowel habit should be as detached and cerebral as su-doku, and modern bowel preparations leave the colon as clear as crystal.

It would indeed be a shame to be put off by lavatorial jokes. Gastroenterology is a young speciality. For many years it was dominated by surgeons, who inevitably neglected those disorders not amenable to the knife. The advent of flexible endoscopy in the early 1970s made gastroenterologists true specialists, skilled in an outstandingly valuable technique. Few surgeons had the time to master endoscopy as well, and an influx of physicians lead to new interest in the medical aspects of gut disorders.

Progress since has been truly astonishing – histamine H2 receptor antagonists, Helicobacter pylori, motility studies, coeliac serology, proton-pump inhibitors, computed tomography, Magnetic resonance imaging and positron emission tomography scanning and elemental diets for Crohn’s disease have transformed daily practice. To be involved in such progress is immensely stimulating, and new recruits need not fear that the rate of progress will slacken. Research, for example, on the pancreas or the metabolic importance of the gut flora will undoubtedly keep any current specialist registrar happily absorbed for the rest of his/her career.

Although endoscopy is vital to gastroenterology, it is not the be-all and end-all. Endoscopy is merely the best technique available for determining the condition of the gut. Successful diagnosis and treatment still depend on clinical skills, for in many patients no clear pathology is apparent and the case history remains the key. Although this may change as new techniques, such as metabonomics, are introduced, currently a high level of clinical skill is required to unravel, for example, a complex case of irritable bowel syndrome, or refractory Crohn’s disease, and success gives great satisfaction.

Furthermore, gastrointestinal (GI) disorders produce many different symptoms, which mean that gastroenterology inevitably overlaps with other specialities. The gastroenterologist harmonizes with surgeons, radiologists and gynaecologists, pathologists, dietitians and physiotherapists. Problems can occur involving cardiology, chest medicine, clinical nutrition, dermatology, endocrinology, psychology, rheumatology and even disorders of the ears, nose and throat.

To encompass such a breadth of medicine, the starting point of training is inevitably the diploma of membership of the Royal College of Physicians. Before seeking a training post, however, it is also a good idea to get some experience of basic endoscopy. Most doctors who have reasonable hand–eye coordination can become excellent endoscopists, but there are a few individuals – often very bright – who get their scopes into such a tangle that one wonders how they ever manage to eat a plateful of spaghetti. It helps to be able to persuade appointment committees that you are not among their number.

It is also very valuable to be able to spend some time on research somewhere during your training. A research degree is no longer essential, except for the most academic institutions, but research provides the opportunity for deeper and more leisurely reflection on clinical problems, and inevitably promotes a keen interest in aspects of the speciality which may be both intellectually refreshing and professionally rewarding at later stages in your career.

The lasting joy of gastroenterology, however, is the patients. There will be many (GI disorders are among the most frequent) and most will be young, positive and cooperative. What’s more, most will have conditions which are readily treatable. This means that there is no need for the gastroenterologist to hide behind the physician’s traditional mask of pomposity; he/she can be confident, outgoing and friendly. Some patients you will come to know and like very well: those with inflammatory bowel disease, for example, need regular clinic visits to maintain remission as the condition slowly burns itself out –with the result that afternoons may come to seem more like old friends’ re-unions than clinics.

At the end of each clinic you may carry away a heavy pile of case-notes, but it will be with a spring in your step! BJHM

Professor John Hunter is Consultant Physician and Gastroenterologist, Addenbrooke’s Hospital,
Cambridge CB2 2QQ and Visiting Professor of Medicine, University of Cranfield

KEY POINTS

• Gastroenterology is a relatively young discipline which is growing rapidly and provides great clinical satisfaction with the opportunity to practise advanced scientific techniques.
• Gastrointestinal endoscopy is an extremely valuable skill which complements, but does not replace, clinical excellence.
• A broad knowledge of general medicine and surgery is required, and it is often advantageous to undertake a research degree during training.
• The prospects for new and exciting advances in gastroenterology in coming years seem extremely bright.te that the author is a coroner.

Article published with permission of the British Journal of Hospital Medicine