The state of gastroenterology training and education in the United States today can be summarized in one word: endoscopy.

Gone are the days of the cognitive gastroenterologist, discussing the character, smell, texture, and color of a patient’s stool in an effort to deduce the pathology that lies within the vast expanse of bowels that could not be explored.  The 24-hour stool collection and analysis is a punchline during Grand Rounds, a figment of the collective imagination of only the most senior attendings, who remember with painstaking vividness the rank smell of the diarrhea they scrutinized.  They stained it, they described it, they looked for meat fibers in it.  Not just for themselves or for their patients, but with the hope that one day they will set the course for future gastroenterologists to better understand the ailments facing their patients.

“A gastroenterologist is an internist first.  Gastroenterology is my hobby, and endoscopy is merely a tool.”  One of my former attendings and mentors, a consummate clinician and educator, a former President of the American College of Gastroenterology, often used this statement as a means to remind his trainees that a true gastroenterologist needed to have a strong base of medical knowledge to be a great clinician.  Anyone could be trained to do endoscopy, but the revered gastroenterologist should be more savvy with his/her brains than with his/her hands.

Unfortunately the current state of affairs among many fellowship programs does not reward the great thinkers and diagnosticians anymore.  “Numbers” is the crucial word.  “What are your numbers?” “How many ERCPs have you done?” “How fast do you get to the cecum?” These are all important markers of experience, but endoscopic talent has become the benchmark by which fellows gauge success.  The “interesting” cases are moreso complex endoscopic procedures and less the diagnostic and management dilemmas followed over a period of time in the outpatient clinic.

Gastroenterology has become the surgical field of internal medicine, and it is not far off before the two fields will see the lines blurred even more with the development of NOTES.  Many gastroenterologists have a surgical inclination and likely considered a surgical career at some point.  There is certainly nothing wrong with being a great endoscopist or a great surgeon.  But there is so much more to gastroenterology that has become relegated to the textbooks.  It is not unusual to find a senior GI fellow who does not know the 4 basic stages of lipid assimilation but knows that the duodenum should be biopsied in cases of chronic diarrhea.

Emphasis on the basic physiology that underlies gastrointestinal disorders needs to be brought back to the forefront of trainee education.  When a discussion about physiology and pathophysiology is occurring on rounds, medical students and residents commonly show much more interest than the fellows do, unless the outcome is, “So when are we scoping?”