The Ups and Downs of Additional Fellowship Training. And we have a great core group here today. We have Andrew, Wasif, and Ashley, and then I will help moderate a little bit. And we're gonna talk about kind of the advantages, disadvantages of pursuing additional fellowship training. And kind of helping you think about decisions. Some of you have probably already even made some of these choices. And we'll kind of go from there and I'll start with Andrew maybe. Yeah, thank you. And thanks to the course directors for having us. So my name's Andrew Yu. I am currently an interventional fellow at the University of California, Irvine. Before that, I actually did a transplant hepatology year. When I was an internal medicine resident, I was very interested in transplant hepatology. When I interviewed at GI fellowships, I was targeting programs that had transplant centers where I can do transplant, get exposure. During GI fellowship, I actually fell in love with scoping and wanted to find a way I can do both. At the time, endohepatology was kind of coming to the forefront. There was an ASGE webinar that I had a chance to see that was given by Dr. Cole that kind of introduced the field and that kind of got me thinking maybe I can do both. So I trained at Emory for GI fellowship. They had the option where you can do what's called the pilot program where the third year of GI fellowship can be your transplant hepatology fellowship. So that's what I did. I did my third year of GI fellowship as a transplant fellow and then I matriculated to interventional fellowship. I was intentional about where I applied to for interventional fellowship, looking for places that did endohepatology and ended up going to UC Irvine where I am now. So the program is 18 months. We get exposure to US ERCP, bariatrics, and a whole bunch of other things, ESD, POM, FORGA things, and it is 18 months. I finish in December, and so now I'm kind of in this on-the-job search looking for a position where I can do both transplant hepatology as well as interventional endoscopy. Thank you. All right, thanks. Hi, I'm Ashley Kniep. I'm originally from West Palm Beach, Florida, and I went to Emory for undergrad, med school, and internal medicine residency, and then I switched gears, so I was in an EMROID, which is when you do all your training at Emory. So I decided to go down the road a little bit and do general GI fellowship at Vanderbilt, and that was a great experience, but I wanted to get closer to home, to Florida, and so I applied to interventional fellowships in Florida and ended up at Advent Health in Orlando where I was working with Rob Hawes and Uday Navanathan and those guys, and then I found employment in Vero Beach, Florida, which is just a little bit north of West Palm where I'm from, about an hour and a half north on the Treasure Coast, and I've been there for nine years now. Hi, I'm Wasif Abadi. I'm at Baylor College of Medicine. I'm not part of the Emory mafia here. So I am, I'm actually, I'll go back a little bit to med school. I'm actually MD, PhD from NYU, and so you can imagine that I've already done a long kind of training after undergraduate and then started getting interested in GI. I saw the way that everybody was working together with surgeons, oncologists, and everybody, so I was like, okay, I like GI. Did GI at Brigham and Women's Hospital, and then from there, I was actually being an MD, PhD, having really basic science experience. I was thinking I was T32, and I was thinking I was gonna do possibly something in IBD, but then I touched a scope and I was like, dude, this is the life. I love this. I can play video games all my life, essentially. I got the interest in interventional endoscopy. I started more working with, being at Brigham and Women's Hospital, there's a lot of bariatric endoscopy. It was a new area, so I was like, okay, well, this is something I could be interested in. This is the newest thing. This is kind of where there's a lot of creativity, so I ended up doing, just like you said, third year, I did a bariatric endoscopy, so I didn't do an extra year for bariatric endoscopy. That was good, and then after that, I did interventional endoscopy as well at Baylor College of Medicine, and then since then, I've been at Brigham and Women's, sorry, at Baylor College of Medicine since then and doing well. And so you're wondering, why is there a pediatrician sitting up here? Well, so for many reasons. Very early in fellowship, I was excited and interested in endoscopy. Actually, Wasif and I have one of the same mentors at the Brigham, and when we spent time there, got very interested in advanced endoscopy, and then actually while I was interviewing, came to a single course topic at ASGE and identified with my mentor, Isaac Reichman, who said, sure, come to Houston, I'll train you. And again, a little bit different format than we have now, but also had interest in liver disease. And so one of the reasons I'm sitting here today is that I am the advanced GI, excuse me, GI interventional endoscopy fellowship director for our program, as well as the transplant hepatology fellowship director. So I have a little bit of insight as well to the program, and I sat for the combined ABIM, ABP, CAQ, so I can at least tell you a little bit about the exam and some of that stuff, but since 80% of the questions are about 18-year-olds and 20-year-olds, not 90-year-olds, I can tell you that that actually is basically the same test. And so, yeah, so I kind of have evolved my training, and I do both advanced endoscopy and part of our transplant team at Texas Children's. I spend a fair bit of time working with the adult group, we call it, at Baylor, and have made great relationships over the years, and I think you'll see and hear a lot of this today about how deep that some of these family trees run, and you will be part of that as well. So maybe each of you could tell me a little bit about some of the kind of pros and cons of that particular fellowship. There's obviously a ton of positives, obviously, that's why you're doing it and why you love it, but maybe some things that you would do a little differently or how you think about it. So maybe start with, a little liver, a little interventional. So I think one of the things to think about when you're looking into doing additional training is the time commitment. The pilot program for liver is kind of nice because you kind of consolidate everything and you're done after three years. But some programs may not have transplant pathology available and you have to go elsewhere. If you're gonna do interventional, you may have to add on that additional year. One of the challenges is that you have to think about an additional move. It's a time commitment, you're pushing off a year of earning potential. And at this point of our lives, you may have significant others, maybe families, and you have to uproot and potentially go to another place just for a year and then think about what's the next step. So that can be kind of difficult, speaking from personal experience. My wife is a pediatric infectious disease physician and we were both in Atlanta. She moved with me to Southern California for this year and a half and she's been working remotely and she's trying to figure out how she can get back to the clinical realm and hopefully at our next stage, we can do what's best for her career as well. So that's something that you have to think about. Your significant others and your family are gonna have to kind of make sacrifices with you if you're gonna move. As far as the other things to think about, during that additional year of training, you're also studying for the boards. For that first four months or so, it's kind of looming over you and you wanna be engaged and really do the best you can. Time is limited, right? You wanna learn as much as you can but you also need to budget time to study for the boards and that takes time away from your, time away from family or significant other and other free time that you might want for yourself. But the pros, as far as hepatology and interventional endoscopy, the fields are moving at an incredible pace and it's been very intellectually stimulating and very fulfilling to learn a lot of different procedures. Even if you may not be doing them in your practice, they're really fun to learn and with new innovations that are kind of coming down the line, these skills are fundamental in allowing you to be able to kind of pick up new skills down the line. So it's been fantastic. On top of that, going to another program, you kind of meet new people, new faculty, you network in that new region and you just kind of expand your circle. Yeah, definitely agree with all of that. One caveat about taking the boards during your fourth year of fellowship is that there could be the possibility that you could push that out to take your GI boards when you get your first job and that's what I did. So I didn't take the boards during my fourth year of advanced training. I was already almost completely signed with my future employer when I was sort of beginning my advanced fellowship and so I had spoken with my future employer about the possibility of them paying for my boards out of my CME money and they said, oh yeah, that's totally fine, you can do that. And after you graduate from General GI Fellowship, you have several years when you're board eligible so you do not have to take those boards the first year or even two out. I think the board eligibility is seven years but most employers in your contract will say something like you need to be board certified within maybe three years. So even though you have that seven years of eligibility, an employer contract might say you need to pass your boards within three years. So those are coming from two different places. You just have to know what your board eligibility status is and for how long. I would recommend not taking your boards during your additional training because I agree with Ben completely. It's just you want to really focus on that time that you have in your fourth year, whether you're doing IBD or transplant or interventional, that time is precious, you don't get it back and so focus on that. Don't worry about your boards just yet. So in terms of cons, I jotted down a couple notes. I can speak specifically for interventional endoscopy. I just out of curiosity, how many people in the audience are either already committed to a fourth year or are interested in applying for a fourth year by show of hands high? Raise them high. So that's a lot of people here. Okay, how many people are looking to do interventional GI for their fourth year? Raise them high, please raise them high, okay. And transplant hepatology? Okay. And IBD? Okay, motility or anything else? Okay. Cool. So how many of the people that raised their hands for a fourth year interventional fellowship are female by show of hands? Let's just see the female interventionalists. Good, okay. So congratulations, that's very exciting. One concern or con that female interventionalists can tend to have is that that time happens to fall right during your childbearing years. And you're under a lot of fluoro during usually your third year of general GI fellowship as you're starting to be at least in the ERCP room and gaining understanding even if you can't really hold the scope yet. And but then definitely your first year out of general GI fellowship when you're doing an interventional year, there's a lot of fluoro exposure. I think that sometimes that concern can turn females away from doing interventional. But I would just, this is a long conversation, I'm happy to have it offline, but I would just say that there's lots of precautions you can take and it doesn't necessarily require standing behind a plexiglass wall to scope. But that was certainly a concern of mine that I thought about, but I think it's very manageable and you can overcome it. So I'm happy to talk offline more about that, but that's a potential sort of concern or con. Another one would be that for interventional, you have to be really careful when you get out of training from interventional because you have to either join a practice where there's high volumes already. So this would be a group where there's already two, maybe three interventionalists and they're saying that they can grow and that they can mentor you and that they're gonna give you cases and not hoard them all for themselves. And so you have to have really good volumes of cases when you first come out, or you have to be prepared to build a little bit of a practice or get those referrals. And this is true mostly for interventional because it's a very skill set that is in its infancy when you first come out. So for example, I had, when I started my job, my first job, I was pregnant with my second child. So obviously I had been pregnant during my advanced year under fluoro for up to, you know, working 12 hours a day under fluoro for up to eight hours a day. And so when I delivered, I had started my new job already, but I was very nervous about losing or not retaining my infant skill set. And so I took very limited time off after that trial because I wanted to get back at the scope. So you could see that as a con potentially, you just really have to be mindful of how you're gonna navigate your first job and making sure you have the volume to maintain your skill set and not taking too much time off even if you're having children during that time. The only other con I could really think of was that specifically for interventional, you are sort of the last line of defense, right? So like you're doing all of the failed cases, you're doing, you know, all of the stuff that is coming in from the surrounding area, you're doing the stuff that your partners don't want to do or can't do, but really just don't want to do usually. And all of these cases do not respect normal business hours, right? And so like you're in a tough ERCP until seven o'clock at night, but maybe that was like the Friday night you have movie night with your kids. Suddenly you're like, you know, finding yourself bailing your partner out who like can't get all the stones out of the bile duct, you know, so like you're basically working longer hours, tougher cases. And that's something you have to be prepared for too. We hired recently an advanced fellow who trained at really good places, a really skilled guy, and so he joined me. I'm the only interventionalist there, and he joined me a couple years ago. And then about a year into doing the interventional work, he told us at our doctor's meeting that he was no longer gonna do interventional GI as an outpatient. So he would continue to participate in our biliary call, but no longer do any outpatient interventional GI work. So then it all fell back on me again, which is fine. But you know, people opt out of especially interventional all the time, is what I've seen. I would love to hear what my other panelists say. And there's many reasons for that, but one of the reasons is like the workload and the hours. It's definitely not a family-friendly career path. So those are the cons. The pros outweigh the cons. Let's just say that, okay? The pros. And you know, when you're thinking about life or medicine or career paths, it's not, you know, you have to, everything has pros and everything has cons, and it's really about, you know, do the pros outweigh the cons, and do you wanna pursue it? So given all those cons, I would say that the pros definitely outweigh the cons. And the pros are that you get to do the freaking coolest cases ever, right? Like, they're so fun. And you know, there's something really special about like going where no one else can go, whether you're like up in the bile duct doing Spyglass, or you're like in the middle of the small bowel in this, you know, obscure occult GI bleeder that has been scoped 100 times from above and below, and you find the AVM that's just like, you know, oozing blood, and you just like get it with your double balloon situation, your APC. So like, it's really rewarding. You know, the other thing I find really rewarding about Interventional is I love removing intramucosal cancers, like just the so cool to like take like a, you know, an early esophageal cancer and just like, you know, EMR it and get rid of it. And you're like, that patient didn't have to have an esophagectomy, like I just like used my little scope, and I just like took it out of there, and they're like all good, no chemo, no surgery, nothing required, like that's a super satisfying feeling. So you can go home to your kids, you know, if they're still awake, and you can tell them that. And you can tell them that, you know, you cured cancer, they may or may not care though. Thank you. Sure. You actually can do it. I have two kids, husband who's a cardiologist down the street, we have a really, you know, we really don't scope after hours, so if you want a job, call me. You can, no, no, no, I don't know what this place is. Thanks Ashley, yeah, there's gonna be differences of opinion. You know, it's very, it's like any job, right? So there are places that you can go, and I agree at the beginning, you wanna have a lot of volume, and you may be busier, but it doesn't have to, your life doesn't have to be that way, so you just have to think about when you go there, when I interviewed 20 years ago, you know, how many people are in the office at 6 p.m. before you go out to dinner with the group that you're gonna be, right? Like, if everybody's there, maybe that's not the place you wanna be. But if you come to Cleveland, see, we're home, five o'clock, you're out of there. So, just saying, you can find it. So like, people who are thinking about advancing off-suite, I don't totally agree that you're, you know, it really just depends where you are. John, Martin, Mayo, how late are you at work? We're usually done with clinical cases by about five o'clock. So, I'm just saying. I think it's different in academics, honestly, a lot of the times. Like, I think if you're in private practice and interventional, you know, I'm gonna talk about this in my contract talk, but, you know, practice setting makes a big difference. So there's different practice settings, like, we can talk to Lisa, who's interventional at the VA, I don't think you know she works past three o'clock, so. Oh, yeah. I love you, Lisa. hold her back, Doug Adler. Yes, Dr. Adler. So, one thing, you said something really interesting about how people leave interventional. And I think also, unfortunately, you can't know your risk tolerance until you're an interventionalist. And a lot of people, when they're like, a first or second year, like, oh, this is the coolest, greatest stuff, and then when they're doing it, it's a lot of risk, a lot of liability all the time. And I think for a lot of people, they just realize that they don't have the nerve. Or like, you know what, I don't wanna live in this extreme high-risk environment all day long, and I've seen more than a few people kind of cut and run for that. They're like, I'd rather do lower-risk cases and sleep at night. And to what Ashley said, you're asked by your team to do the things that they're not willing to do. You're also asked to do what the surgeons aren't willing to do, right? So, you really are a hybrid profession, and that kind of the, you know, you're just in this awkward place, but it is so rewarding. Yeah, and even the IR guys, like, they'll come to me, like, they're asked to do a percutaneous biopsy. I just got one, like, the other day. You know, it was a crazy, like, adrenal mass or whatever. You know, and they can't reach it, you know, and they're like, will you do this? I'm like, okay, yeah. Like, everyone's just always asking you to do cases. Like, you know, the E-bus guys, the interventional department, I couldn't get a thing. It was, like, closer to the esophagus than the trachea, so, like, I'm, like, biopsying something in the lung, you know, like, so, I mean, it's just, there's just, you know, whatever, it's a lot. And the flip side of that is that they will, they'll be like, what were you doing? It's like, why were you in the lung? Why are you in the adrenal gland after they tell you to ask you to do that? But then they ask you to teach them how to do it. That's the other thing that I've come to realize, so thanks. So, there's a theme going here. It seems like the people who have done interventional or done fellowships, we like to shirk responsibility and push it out as far as possible. Do your boards the next year, that's great. I did MD-PhD, and then I was like, you know what? I want more training, and then continued doing training. I'm sure my wife didn't really help it. But it kind of, you have to realize you are putting a lot of time into it, and, you know, for me, having done, you know, eight years MD-PhD, and then continuing and doing fellowship, and then telling my wife, hey, I kind of want to do interventional endoscopy, it's a lot, and taking that time is a lot, but the advantage is definitely, definitely there where you are doing something that you like. The other thing that I wanted to quickly point out was that, I love what you did, we're trying to kind of point out everybody's here, but the people who didn't raise their hands and didn't say, you know what, I'm not doing an interventional endoscopy, I'm not gonna do advanced training, I like what I'm doing in GI, you might at some point realize, you know what, I really do have an interest in X, Y, or Z, and that's okay. You don't need to do a whole fellowship to start getting training in certain areas. You can start finding resources. It's harder, it's not easy, where you could just do a year and do things, but you can start shadowing people, you can take a little bit of time and start working with people, people will help you. So we have a huge ESD program at Baylor College of Medicine, ESD Poem and everything, and I do see people coming in and trying to train with, I don't particularly do ESD, I'm more bariatric, but we'll train with Muhammad Uthman, and they've been out for like five years, and they're still training there and trying to get their courses, their AHE courses, so it's okay, don't worry, you're doing great. General GI has so much interesting stuff, but if you ever find something that you wanna have a little bit more training in, there are lots of resources, so don't worry about those. And there are kind of choose-your-own-adventures, and although there are only a few IBDs, and you're just right in front of me, but there are, if there's something that's very interesting to you, you can talk, if a program has a need, you can say, hey, I wanna do this, and maybe you can have a focus, and you become the sixth advanced fellowship in GI. So those pathways are still possible. Fill in the blank. If I knew then what I know now, I would, Wasif? Um, I would do it all over again. Great, that's great. I really, it's a lot of time, but I really like what I did. I probably would have just kind of, I think I would have picked my route a little bit earlier, and I think I kind of slowed down and kind of realized where I really wanted to go a little bit later, and it took me a little bit of time to get there. My question for them is, what would you tell your PGY7 self, but you would be like PGY13 or 14. So, Ashley, how would you fill in that blank? Yeah, two things. I would say I would pay more attention to personal finance. I think that I felt really prepared coming out in terms of the GI stuff, but what I wasn't prepared for was that big paycheck, and I really didn't know what to do, and I had some shark personal finance guy who I aligned myself with in med school or something, and he ended up just being an insurance salesman and not fiduciary, not in my best interest, so I went through this sort of odyssey, if you will, about learning about personal finance so that I could manage my own money, because no one's gonna manage their own money better than you, and so I would have told myself back then to learn more about that, and then I would also have told myself to really focus on ergonomics. Ergonomics are real, and there's a lot of injuries in endoscopy, especially for interventionalists who scope all the time, and so focusing on those, listening to your body, getting help early if you're starting to have pain or discomfort. So what would you tell last year's self or version of you? Yeah, I would tell myself to stick with it. One of the, I guess like the, I was a little apprehensive because endohepatology was kind of new. I wasn't sure, kind of from my experience, I wasn't sure how the hepatologists were gonna kind of receive this. I wasn't sure how the interventional, where I would be able to kind of fit in from the interventional side. I'm kind of this mutant form of both fields, and so how do I kind of create value for a group? And now I'm kind of in the job search, and so far everything has been very well received. So going to societies and meetings and kind of meeting other hepatologists, and hey, like I'm learning this new skill set, like what do you think? And some people will say no, like you shouldn't be putting a needle in a liver like that. But some hepatologists are like, yeah, like we're trying to build that in our program like that. That would be a great fit. And so that's been really encouraging. So I would tell myself to kind of stick with it. There will always be doubts and imposter syndrome, but yeah, stick with it. And I'd say that was kind of my experience. I'd met with some people like, well, we don't really need that. And then you'd realize actually they do need it, they just don't realize it yet. And so, and even some of those programs 20 years later that they still don't have it and they don't get it. And so I think that for me was enlightening. And I remember for endohepatology at least, I didn't have that name. And I had an interview and someone said, I don't get it, how are you gonna combine them? And I was thinking, well, Varices and PSC, and I thought it made perfect sense. Then we went to dinner, that individual was there, and everyone was like, isn't it great, he's gonna do PSC. And all of a sudden it was like the sky's open and everyone's like, oh, I see that. So I think you do kind of need someone to kind of get behind your idea and your passion. Even if they don't see it quite yet, but you can see the trajectory. I think that's really important. Anyone else want to answer, the faculty want to answer the kind of, if there was one thing that you kind of, if I knew then I would do it a little bit differently? I mean, I think we're all here, we still like it, right? I just have one comment, Doug. So I agree with the ergonomics is a big issue. So I was, I'm getting close to 60 and I'm really having a hard time with my hands. The other day I was doing an ERCP and my thumb like completely locked. And I don't know how to say how you can prevent that, I think as women especially, to the women with our smaller hands. Because when you talk to men, I don't know, I mean, I know one of my colleagues who's male has that problem, but talk to others like Doug Rex, you know, who's probably done a bazillion colonoscopies, has no idea what I'm talking about. So I think ergonomics is really important, but also think about it when you get your job. I mean, advanced, you do a lot of procedures. I do three and a half days. So it's fun, but you know, it does take a little wear and tear and you got to sort of maybe think about that. Although I think that's pretty hard when you're first starting, you want to do as much as you can. But I think ergonomics is a big issue. But at least we're more aware of it now. Whereas, you know, when I first started, we weren't. So I'm thinking about fatigue mats and where the screen is. And I don't know what you about the hands, but. Yeah, the hands, I mean, it's important that the umbilicus is outside of the left arm and not inside, because if it's inside, like my main issue is that I have this problem here where the scope head rests, especially the heavier scopes, like the linear EOS scope. So you can prevent it by just having the umbilicus in the right place. But I was working for, you know, many years before realizing that my umbilicus was in the wrong place. And I tried to change it. It's very difficult to change. And then there's just other little things. Like now the scopes are lighter. They have newer generation of scopes that are actually lighter. But Ashley's right. Like these issues affect disproportionately women. So one interesting like factoid is that the grip strength, the hand strength of a 65-year-old man is equivalent to that of a 35-year-old woman. So you just think about that. You know, I have, I'm only 43. I have like terrible arthritis in this finger already because I torque the scope with that finger. So it's just something, you know, to make sure that you pay attention to those ergonomic talks. Go to the ergonomic talks when they're offered at conferences. Talk to your, you know, attendings about ergonomics and make sure you take it seriously because the percentage of, you know, docs who have like low back pain, for example, from like resting their thighs on the stretcher and leaning forward as they scope and not standing straight up, like these sorts of things, you'll get low back pain over time. Swatsy's gonna talk this weekend and I've kind of championed it both in pediatrics and within some of this group, both with the guideline and other things, but I've been using the Canadian C technique. I tried to get Ashley on it last year, but I'm happy to try to brainwash any of you and to think about some of these techniques and a little bit different, perhaps what Ashley's talking about, but anyway, ergonomics is incredibly important. And again, thinking about it now, I was 10 years, 15 years into faculty before it was really a thing. There were a couple comments from that. You guys are all not gonna listen to any of this ergonomic talk because you all think you're indestructible because you're not hurting yet, but over half of you will have an injury. And I've spoken before, and if you like see pictures of me on Twitter, I'm wearing a brace on my left hand. Like I put that brace on my hand when I get out of my car in the morning and I do not take it off till I get in the car in the evening. Like that honestly, that's the most important thing because once you get these injuries, good luck getting rid of it when you've got 14 scopes on that day. Other comment? Yeah, just wanted to make the point that it's important to realize that practices are very, very different. You need to be an opportunist when you're looking around. Our schedules are very different. What we do in our practices are very different. You know that residencies in medicine were more alike than fellowships. And advanced fellowships are more different from each other than three-year GIH fellowships. And when you go looking for your career job, they're all gonna be very different. I'm usually done with clinical work at five, but my room is actually running with a patient in it at seven and we don't take a midday break. And our rooms are extremely efficient. So the day is very concentrated and it's very hard to work on a paper during the middle of the day. It's sometimes hard that you have to skip lunch to keep going, but you do get done early. And because our practice has a lot of interventional endoscopists in it, there's a lot of coverage. And so when you do take call, you're busy, but you don't take call as often. So don't be afraid that, oh, life's gonna suck. It's not gonna suck. You just have to find the practice that suits you. And the practices are every bit as varied and different as you are individually. It's finding the right fit. It's like any relationship in life, your friends, your spouse, your career. That's a relationship too. And it really matters what your relationship is with the people that you're gonna work with. In fact, that's probably the most important thing is are the people in the group congruent with what you value in your life? Not just your career, but your life. And that's where the happiness equation computes. I totally second, third that. The people that you're working with is a huge, huge difference. The hospital could even suck. It can try to drain the energy out of you, but if you're with people that you like working with, you will support each other. It'll just make your life much happier and vice versa. If the people are terrible, they will, it might be a high-paying job with lots of luxuries and everything, but you're gonna be miserable. Did anybody go to summer camp, sleepaway camp? It's like you rough it and you're miserable, but you're miserable together and misery loves company. And years later, you're all still friends. And that's kind of how I feel about it. Not that Baylor College of Medicine and TCH are miserable. Any questions from the fellows? We actually have one from the virtual audience. Yeah, so any pros and cons to doing something more niche like a Women's Digestive Health Fellowship? There are one at BI. I can take that since I'm a woman, I guess. I didn't even know that that existed at BI, but that's really cool. Oh, absolutely. Like I was just, a friend of mine, I'll tell you a quick story. Friend of mine who's an OBGYN in Vero, she just opened her own practice, which is like a women's health clinic. So she recruited two GYNs, two female primary care doctors, and she tried to recruit me for GI. And she has this neat little niche practice in the small town of Vero Beach. And so it's just, it's actually partially concierge, but you could set it up differently, of course. But it's like highly successful. And I think women want to either go to maybe a multi-specialty sort of group like my friend Christy has set up, or to a GI-only group. I think I was the only female in my group of eight for many, many years. And there are so many females, especially of certain religious backgrounds, or if they've had bad sexual trauma in the past or something like that. I mean, they will really only get their colonoscopy done by a woman. And if there's no women available in the area, they're just not gonna get their colonoscopy done. So that's the extreme end of the situation. But my male colleagues failed to sort of recognize how important this was to some of our female patients, when they would just sort of like, well, we all do a good job, and we all can get to the CECOM and stuff. So, but no, no, I think that that could be a really nice niche. Going into a niche, and bariatrics is kind of a niche. It's not really anymore, but when I kind of started it, there weren't many people doing it. But just kind of thinking about kind of a small area and getting training in a small area. First of all, if you really like it, do it. It's something that you really like and you'll enjoy. You need to have some skin in the game. This is what I like to do. This is, for people who are in academics, are it's, and this is kind of goes into the academic talk later, but you kind of need a little bit of a niche to set yourself apart and to kind of put yourself out there as something that people will invite you for. Like, hey, we want to talk to you, have you talk about this. So it's important, and I highly recommend it on any area of a niche. But it does limit your scope of where you're going to be working. So if you're already working and you kind of say, well, this is something that is needed, and I like this niche, and I want to go into it, that's a different story. But if you say, you know what, I'm in fellowship, a lot of people who see certain heritable pancreatitis, for example, and I want to make that my niche. And then you find a job, and there are like two patients that you can find in a year. It just really won't be your niche, and it won't really be something that you're going to be in. So it has to be, you'll have to really look at where you're going to be working based on that. And the flip side is that you might develop a new niche. I mean, I wasn't really as much interested in the pancreas, but there's so much, we do a lot of chronic pancreatitis at Baylor. We do a lot of pancreatic cancer and all that stuff, which now is everywhere, obviously everywhere. But just that kind of that area of interest, it just wasn't a lot of people doing chronic pancreatitis. So we said, okay, let's do that. And it became, it developed an area that we were interested in. So definitely recommend doing it if you need, if you're interested in everything, but it will limit your job prospects. It will limit, and you may have to make sure you have those patients, and you have to go out there and look for those patients. And I would just add two things. I'm certainly pro-fellowship, right? I'm a fellowship director. And I think it's good. I think if you have that time to spare, go for it. And also you never know when you're gonna use it. You can, obviously, CoreGI will always be there for you. Core Hepatology will always be there for you. But you never know when you're gonna have an opportunity. For myself, we had someone who was a full professor, went somewhere else, and I was the only CAQ transplant hepatologist at our center. So there I was, very early in my career, just for a couple years, interim director of our transplant program. So sometimes there's leadership things that come up that you're not expecting, and because you have that advanced skill. The other thing I would say is, and I don't wanna say it's only for academics, but it probably is emphasized in academics. If there's something you're really interested in, but the program has some other need, they may allow you to investigate your area a little bit if you do a little bit of what they need. So short bowel syndrome, or EOE, or something, but you wanna do this, then that might be a little bit of an entree for you to be able to get what you need, and the program gets what they need. So just something to think about as you're investigating training opportunities. Other questions from this audience? If you decide to do a year of general GI right after your training, and then apply for an advanced fellowship, does that work against you as an applicant? We're talking about female GI again, I think, right? So, I don't really know the answer to that, because, like what, I guess more information, like what an interventional do you plan to do that relates to like Euro GI? So like in advanced, it doesn't mean Euro, so I'm in my second year right now. We will be doing a year of general GI, and then personal reasons, and then maybe applying for an advanced fellowship. But how would you marry your advanced training with your Euro GI training? I would say year of. Oh, year of, I'm starting to think that she's, I'm like, okay, a year of, okay. I'm like Euro GI, because there's Euro gynecology, we were just talking about like women's practice, like now we're doing Euro GI fellowships, what? I stayed quiet for that reason. Is that like the same, is that the same as like pelvic floor, manometry, and dyssynergia? Okay, anyway, yeah. So now that we're doing it, saying a year of interventional, so what's the question again now that I understand? So you're talking about a? So I'm just saying, so most people apply for an advanced fellowship during the second year of. Oh, so you're gonna take a year off is what you're saying? Yeah, exactly. Oh, okay, yeah, a year off. I don't know, I'm not. We love to shirk responsibility, so we say go for it. Yeah, go for it, for sure. I think it depends. It's perfectly fine, you can take a year off. You can do something, there are people who've worked for one or two years. Honestly, I probably, the fellowship directors, you can speak as a fellowship director, but they don't necessarily like it once you're further out, but I think a year or two of experience kind of gives you a much better sense. You learn a lot as of, I mean, you think your fellowship ends at year three? No, it ends at like year five or six when you get all that experience and you're continuously figuring things out. So it's okay to take a year off and then apply for a fellowship. It's just, we really don't look well upon it after five, six years, you're then applying, you're like, okay, but I don't think we should necessarily, but a year off is not good. I had a couple of co-fellows in my interventional program that had taken a significant amount of time off after they finished their general fellowships and had families, and I think in practice, they developed new interests and then kind of went back into training and did their training and then are now working in things. One of the fellows had to travel. He had left his family in the East Coast, came, would train Monday through Friday and then on the weekends go back. So that was kind of brutal for that guy for a year. The other guy had moved his family. So there's that aspect if you're gonna take time off. From a personal standpoint, or just to play devil's advocate, I feel that there is some momentum when you're a trainee, if you just kind of keep going and going, like you can kind of take that inertia and keep going. If you take time off, not to say that you can't do it, but some, you may lose that momentum. I would just add, and maybe there's a couple, if there's a comment and we'll close, but I think it depends also what you do during that time, right? So if you're, I think if you use that to try and learn how to use the duodenoscope, if you're trying to get some exposure during that time while you're doing it, but if you have zero kind of exposure, it doesn't mean that you can't be part of that, but it just, I think it demonstrates, hey, even in that year I did this, or I plan to do this, I think that's important to hear that what your pathway is and how that extra year will influence you. And there's also this take time to sharpen the saw, that seven skills of the highly successful people and taking some time to kind of, let your body rest for a year or two. I think we don't recognize that and we probably should as well. So I think that's variable. I don't know if anyone else has comment about taking time off further if they had a fellowship applicant. I think it's variable. I will just say that it might not be time off. Yeah. Yeah, no, yeah, no. It might be really hard work, right? We're not trying to minimize in any way the work that you will put in in those one or two years. I just wanna be clear about that because it might actually be really rigorous, general GI work that you're doing, right? So, and then coming back into intervention also. But it's also okay to do a little less as well if that's what your goal is. Locums is, I don't know if you guys have ever done locums. I had a delay in starting my job for because of Baylor takes its time. So I did a few months of locums and oh my God, it was fantastic experience. You get to travel, you go out and go places and work. But you're sort of, you start getting your experience without any stuff really following you. Whereas if you start somewhere, they're like, my God, this person's terrible. He doesn't know how to do this X, Y, and Z. All the nurses are talking about you. And it's like, I didn't have to deal with any of, I kind of like, just like, okay, let me get myself. And they're so happy that you're there regardless. They're just like, okay, great. There's somebody who can cover the week, kind of cover the weekend. They're just like, okay, let them, it's like, let them do whatever you wanna do. So it was a good experience for me. Yeah, I agree. I appreciate everyone's expertise on this. And again, please find them, ask them any of us questions about training. And as you said, we're not shy. We'll tell you what we think and what we don't think. Yeah. Great, appreciate everyone. I'm glad to know there's not a new UROGI fellowship that I was unaware of. I was starting to feel really old. I'm like, wow, we are really branching out now. Okay. All right, thank you. Thank you.

fellowship training

medical training

interventional fellowship

transplant hepatology

radiation exposure

supportive work environment

professional demands

personal life balance