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Session 113 Dr. Aaron Leetch one of the program directors at the University of Arizona for a combined residency in pediatrics and emergency medicine. It's actually a very rare residency program with only four programs in the country that offer this. Find out more about this, how it's different and much more! Dr. Leetch is the host of the Arizona EMCast. Also, check out all our other podcasts on Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:27] Interest in Combined Pediatrics and Emergency Medicine Aaron has always been certain he was going to be a pediatrician as he loves working with kids. He also liked the compassion of it. It was when he started working at one of the local ERs as a scribe that he felt torn between pediatrics and emergency medicine. He loved the acuity and multitasking aspects of emergency medicine. In fact, he likens it to waiting tables which he used to do. Then he met the program director at the University of Arizona who trained at the combined emergency medicine and pediatrics program in Baltimore and started the program there. He asked Aaron why he wanted to do both and thought it was everything he had wanted to do. After five years of doing the training program, he still loved every minute of it and knew it was the kind of thing he wanted to do for the rest of his life. Aaron has always been amazed at people being torn between two specialties that are very dissimilar. For some people, pediatrics and emergency medicine are not the same. But he explains that there are aspects of both sides that he really liked. Aaron later realized that his pediatric training would be applicable when he sees children in the emergency department. To help them navigate that system in the ED is incredibly helpful to the patient.  [Related episode: What Does the Pediatric Residency Match Data Look Like?] [06:40] Traits that Lead to Being a Good Combined EM and Pediatrics Physicians You have to be patient considering that it's a five-year training. Be sure that you're willing to do five years since you can just do emergency medicine and still trained to see children. The first thing he looks for in applicants is why they want to do both programs. He also wants to know people have considered what they want to do after they're done with training. There are lots of EDs that can't afford to hire somebody who's only certified to see children and they need to see both. [Related episode: Advice From an Emergency Medicine Residency Director] [08:38] Getting Exposure for the Program Considering that there are only currently four programs doing this kind of training in the country, they're hoping to gain visibility through doing medical student podcasts. Plus, they also get the opportunity to talk to people about this. The most common for pediatric/emergency medicine is doing a peds or emergency medicine residency and then doing a fellowship. This is great as long as this is what fits with what you want to do. However, if you want to be a rural doctor and you want the general pediatrics knowledge or the subspecialty time with pediatric nephrology or neonatal ICU, you wouldn't be able to get this by just doing an emergency residency and the pediatric fellowship for two years. It would not give you the same level of intensity if you want to be a broader trained person rather than narrowing and being a specialist. [10:50] Types of Patients The types of patients you see depends on where you go. In Aaron's case, he does 60% peds and 40% adults. You have the potential to work in any emergency medicine department across the country. If you want to work in a pediatric-specific emergency department, that depends on the needs of that emergency department. You could open up your own clinic if you wanted to or work in places that need a general pediatric physician as a hospitalist. You can do a fellowship on the emergency side or on the pediatric side. Or you can do both. In their program, they've had people who did fellowships in pediatric critical care, simulation and medical education, toxicology, sports medicine, and some other ones. You've got a lot of opportunities when you're done assuming you keep your options opened for geography. Make sure you've got a good idea of where you're headed. As fellowships are becoming more common after residency training, you need to be able to stand out. However, you don't want to do this just to stand out because it's a long chunk of your life to spend. There are better things you can do. But it does help and it gives you a different philosophy for how you're approaching things. [Related episode: 5 Traits Patients Want Their Doctors to Have] [14:20] Trend in Medicine for More Specialized Specialties If you have an idea of where to go, then you need to email that institution and ask what you need to do to get the job. That said, there are plenty of places that are still clamoring to get somebody who is a specialist and wants to take ownership of pediatrics. There's a lot of literature suggesting that people who have done the pediatric EM fellowship stay in large academic centers. They don't go out into the community and work as they had hoped. In fact, many have now questioned whether centralizing everything at the children's hospital is still the best way to go. Aaron feels that if you've got extra training, you feel more comfortable seeing children. You feel more prepared to see a really sick kid out there because that's where the majority of these kids are going to end up going. For their program, Aaron explains you have to have the pediatric experience. You've seen kids, especially the really chronically ill kids, and the tech-dependent kids. You've seen them in the clinic. You've seen them at the subspecialist's office. You've seen them when they're really sick in the ICU. You've got a background on how to take care of children that you can pull from. And then you've got procedural competency and that critical care emergent time-management mindset from emergency medicine. The other five years of training just becomes a part of you. [18:30] How to Know If You Have the Procedural Competence If you can get any experience during medical school, you will decide very quickly whether you love procedures or you don't. There are a handful of environments where residents and attendings tell you how they've walked into X environment and they knew they're home. For some people, that's the O.R. For some, that's the clinic or the ICU or the ED. If you have the opportunity to do any kind of three-week elective or some experience ahead of time, do it. Email a physician and ask if you can shadow them even just for one shift or overnight or for one time that will allow you to get the best exposure. A lot of what they do in pediatric emergency medicine is to convince their kids are going to be okay as well as a lot of return precautions. If you don't like doing this then pediatric emergency medicine is probably not great for you. You're not constantly having critical children coming in.  Regardless of what you're considering, try to get some experience early and that will help you make your decision. [21:00] Work/Life Balance and Taking Shifts Aaron still gets to have a life outside of the hospital. But he believes you have to make time for it. He makes it a point to take time out apart from doing anything related to work to recuperate and refresh. With shift work, you've got to work 365 and somebody's got to work the holidays. Somebody's got to work the overnights. So you adjust to it. And if you're considering emergency medicine of any kind, you have to determine whether you can function at 2 am. And are you somebody that someone wants to be around at 2 am? Or do you turn into a werewolf that nobody wants to work with? You have to make it a point to do something that is not medical after work in order to restore yourself. At their program, they've got a handful of people that just do nights. They're offered a pay differential so you can make a little more. But they would usually split between mornings and evenings. The morning shift can start as early as 6 am. They work 9-hour shifts. And it can start as late as 5 pm and you get off at 2 am. But in an emergency, you get off when everything is done, especially as a resident when you're still trying to learn your flow and your management. But you will get better over time and things will get tolerable. As a resident, everybody rotates through in a circadian fashion so that you do as much as you can. But you do a lot more evening shifts because that's when the patients come in. Even if your sign out is done is at 4 and your relief comes in at 4, then you're not done for another 30 minutes so that the transition of care is appropriate. And this is expected. Aaron gets off when he's supposed to probably 60% of the time. Especially in pediatrics, most of the kids they see are not critically sick. So when he works his adult shifts, he always buffers knowing that a lot more adults are going to be critically sick and they're going to need his time. But you're never really prepared for that stuff. [Related episode: Balancing Family Life with Being a Premed and Medical Student] [26:45] The Training Path If you want to do pediatric emergency medicine, you can do a three-year pediatric residency and the three-year pediatric emergency medicine fellowship. You can do a three or a four-year emergency medicine residency. Then another two or three years in pediatric emergency medicine fellowship. At their school, they have a five-year program where you have to fulfill all of the requirements for emergency medicine and all of the requirements for general pediatrics. They're doing this concurrently. They do somewhere between 2 and 6 months in the emergency department doing trauma surgery, ICU at the VA, emergency medicine, anesthesia. Then you'll flip and do 2-6 months of general pediatrics, neonatal ICU, pediatric pulmonology, inpatient wards, clinic. Then you keep flip-flop back and forth until you reach your five years. Aaron likens their training to children growing up in a bilingual household. They don't necessarily keep the same verbal milestones compared to a kid growing up in a single language household. They're learning two different words, two different idioms, and two different ways to say the same thing. But once they do, they catch up pretty quickly and they speak two languages. With their program, they're going to teach you how to speak pediatrician and how to speak emergency physician. Although, it takes a little bit longer.  It's a different growth curve of how you're going to progress along in your understanding of both specialties. But once you do, you're going to catch up. You may even surpass some of the residents from either the emergency medicine or the pediatrics program itself because you now speak two languages. [29:45] How to Be Competitive for This Program The four programs that offer the combined residency include the University of Arizona, University of Maryland in Baltimore, Indiana University in Indianapolis, and LSU in Louisiana. There are only 8 or 9 spots in country. Aaron says that you have to consider if you're crazy enough to do five years. You have to love this enough that you want to do five years To make yourself competitive, have a backup either in pediatrics or emergency medicine. Some people choose both. And even if you don't match into one of these spots, you can still do emergency medicine and a fellowship or pediatrics and a fellowship. They've even had several residents that graduated from one program and then re-entered the match and did the other ones. So they did six years to do the same. Well, it's not quite the same because you're taking it in chunks instead of intermingling it. Aarons recommends that you strengthen your application packet towards whichever is going to be your backup. So if your backup is emergency medicine, then strengthen your packet towards emergency medicine. Show that you're going to be a good emergency medicine resident. Doing away rotations is great as well as interview rotations to have a good idea of what's there.  Do pediatric emergency medicine or pediatric ICU as they're going to be helpful whether you do the combined EM/peds program, EM on its own, or pediatrics on its own. Both are going to intersect with peds/EM and peds-ICU. This will help strengthen your packet for the combined program and for whatever your backup is going to be. [33:40] Applying as a DO and How to Stand Out in Rotations Two of their residents at their program are osteopaths and they're fantastic. If you're applying to a place that already has unfavorable opinions set on osteopaths, go for it if you want to be the trailblazer and try to rotate there. Otherwise, consider if it's really the best place for you if you're not going to be viewed as an equal with the other residents. Aaron adds that you can strengthen your application just as you would for any other place. But if you feel like that may be a hindrance for you, doing an audition rotation is a great way to show how good you are. To stand out at these rotations, you have to show initiative and that you can work well with a team. They want to see that you've done some of the work on your own. There's also the 2 am test. Are you somebody they want to be working with at 2 am? You have to be reliable. A fit in personality is also important to consider. Their program wants to see that you fit well. So you have to consider whether you're a good fit at a certain program and determine if you like them. [Related episode: The One Thing You Need to do to Stand Out as a Premed] [37:30] What He Wished He Knew That He Knows Now Aaron wished he had done a much better job with self-care and making sure that he took time (that he now takes) for family, for friends, for hobbies, and for things that help maintain his sanity. Although residency is not as a brain-drain that medical school can be where you feel like you're drinking from the firehose, it is time and energy-taxing. You have to put effort into the things that you want to be around when residency is around like family and friends. Because you can't just push pause and come back in 3 to 5 years and feel like everything is still going to be the same. [38:50] The Most and Least Liked Things What Aaron likes the most about the combined residency is that they are people who like to have fun and have a broad perspective of medicine. What he likes the least about the pediatric emergency medicine is that when it's bad, it's really bad. They deal with cases like child abuse, pediatric sexual assault, drownings, SIDS, and cancer diagnosis. Often, those will happen in the ED. What he realized that really affected him is that they can't help everyone. They want to take care of everybody that's there. They want to try to help every person that comes into the emergency department. But there are so many people that come in with complaints that they can't help. He tries to provide hope for people in a hopeless situation when they come in at midnight on a Saturday. For him, this is frustrating when you can't offer what they want. [42:35] The Overlap of Pediatric Care and Adult Emergency Medicine Especially during residency, you spend a lot of time in the clinics and on the wards. They even joke around that kids are not little adults but adults really are just big kids. Aaron says he can do a lot of the same things that he does with children. He's able to apply some of that to adults especially among the 20-year-old's where the overlap is not quite there yet. In pediatrics, one of the first questions they ask themselves is whether the patient needs an IV. In adults, before they even get their chief complaint, they've already gotten an IV. They're getting a dose of antibiotics and they're on their way to the CT scanner. All those being said, he gets to have a different perspective. If he had to do it all over again, he'd still be a combined EM pediatric physician. And even his wife just recently told him that if he had to do it all over again, she would still support him all the way through. [45:25] Final Words of Wisdom To those interested in getting into this specialty, try to get experience in both emergency medicine and pediatrics because they want to train people in both. They want you to be a pediatrician. They want you to be an emergency physician. Then they're going to train you on how to be a pediatric emergency physician. Make sure you really want to do both because the last thing they want for somebody is to be halfway through and say they hate this. They want you to go in with eyes wide open. Links: Meded Media Arizona EMCast

March 11th, 2018, Trinity Baptist Church of Katy, Pastor Josh Guajardo Discernment, Knowledge and Wisdom " To one there is given through the Spirit a message of wisdom, to another a message of knowledge by means of the same Spirit, to another faith by the same Spirit, to another gifts of healing by that one Spirit, to another miraculous powers, to another prophecy, to another distinguishing between spirits, to another speaking in different kinds of tongues, and to still another the interpretation of tongues." -1 Corinthians 12:8-10

Session 34 Dr. Sushil Duddempudi is a community-based Gastroenterologist who specializes in interventional endoscopy. He has been in practice for ten years now and specifically as an interventional endoscopist for the last seven or eight years. He used to be in academic hybrid private practice. Check out what he thinks about the field and what you should be doing if you're interested in this field. Also check out all our other podcasts on MedEd Media Network. [01:45] An Interest in GI and Interventional Endoscopy Dr. Sushil Duddempudi knew early on that he was going to be in a procedure-based field. It's a running joke in the field that GI people aren't smart enough to do anything else so they use procedures as much as they can. Then leave the complex stuff to the nephrologists, neurologists, and everybody else. Sushil started residency leaning towards cardiology until realizing he hated EKGs. So he gravitated towards the GI field. He says it's not uncommon for students somewhere during their intern year where they're interested in one area. Once he started the GI fellowship, he knew he was into doing procedures. He found interventional endoscopy as a good fit for him because it lets him do procedures most of the time. But he still has this continuity with his patients which he loves. So about two-thirds to three-quarters of his time is spent doing procedures. Then maybe a quarter to a third is spent in the office seeing patients. "GI is a pretty cut and dry field compared to some of the other fields." Sushil describes they usually have a definitive diagnosis early on after seeing a patient and he likes the finality of it. GI borders that surgical mindset and a lot of GI's have mindset.They see a problem and they want to take care of it. Also with GI, there is finality. If the patient has rectal bleeding and you had a colonoscopy then you'd have an answer 99% of the time. When patients have abdominal pain unless it's functional, most of the time, they come up with an answer. Moreover, Sushil likes the opportunity to do procedures. Other specialties he did consider include ENT or Neurology which would have probably worked for him as well or one of the subspecialties that are procedure-based. Ultimately, he ended up in GI. [04:40] Traits that Lead to Being a Good Interventional Endoscopist Sushil describes how many of those starting GI fellowship often say they want to do interventional endoscopy. Then over their first year or two, they'll select out. "You have to enjoy doing procedures." Some fellows he has worked with and trained over the years come in with a certain special knack. Some people just have good eye-hand coordination better than others. 90% of it can be taught and trained. But the people they look up to in the field are born with a little bit of it. This is what Sushil differentiates them from the rest. They are the guys doing the hard core cutting edge stuff. So it's a bit of something you bring within you into the fellowship and then 90% of it is just practice. [06:15] Patient Types and Typical Day If you're an academic interventionalist, you can tailor your practice to focus on that. This could mean 75% of your practice doing procedures. Community-based interventionalist flip it all the way around. In gastroenterology, the bread and butter is still colonoscopy. If you're a community-based interventional endoscopist, you could be doing around 25-75% general and then the remainder is advanced interventional endoscopy. Then as you get older and you've done all the cutting edge stuff and you want to settle in a little bit, you can then focus on general gastroenterology. Then you can do the interventional stuff maybe 25% of the time. For general GI, the younger groups tend to come in with more functional disorders and abdominal pains. As they get older into their 50's, they start to do a lot of colonoscopy screenings. Also in the 50's and 60's, they start to see a lot of GI cancers. "Interventional endoscopy is very focused on GI cancer. That's where a lot of the techniques are being used." For general gastroenterologists, most of them will do roughly about a half day in the morning. They start at around 7 or 8 to about 12 or 1pm doing endoscopy. Generally, you are in an outpatient surgery center. Then the afternoons would be spent in the clinic. Sushil says that more and more gastroenterologists are coming out of the hospitals and staying in their office in surgery centers. Moreover, a new breed of GI hospitalists are starting to happen where you're focusing on inpatient training. This happens less in the big cities. But generally it's a mix of outpatient procedures an outpatient office visits which is 90% of what gastroenterologists do. While the other 10% would be composed of inpatient. If you're an interventional endoscopist, you'll me a little more focused on the in patients because that's where a lot of the work comes in. This involves cases like bile duct construction, GI tract tumors, etc. Although they see this in the office, a lot of work comes in the emergency room. In Sushil's practice, the way they do it in the group is that most time is spent in the hospital early on. Then after two years, you will transition out to the outpatient side. So the new guys coming in cover all the hospital work. Then the partners are just focused on the outpatient work. "Like many practices, it transitions over time based on your interests, time constraints, the type of practice you have." [10:56] Work-Life Balance Sushil didn't actually feel he had any work-life balance. But he would say that in general, interventional endoscopists are in the hospital the latest. "It's definitely a field that you're committing extended hours compared to general GI guys." This is because more of your work comes in in the inpatient setting which is always unpredictable. Your day could be extended. And the procedures you do tend to be a little longer . They are a bit less predictable than a colonoscopy or endoscopy which you can do in fifteen-minute blocks. Interventional endoscopy procedures are a bit harder to put into certain blocks. [12:30] The Path to Residency and Fellowship For interventional GI, sometimes called advanced endoscopy, you do your three-year medicine residency. Then you do three years of general GI fellowship. And then there is another year of sub-fellowship. This has actually has crept up in the last five to ten years. Currently, there is only one ACG-accredited post GI fellowship that is liver transplant. And there are are five non accredited which include interventional endoscopy, clinical hepatology, motility, inflammatory bowel disease. Interventional endoscopy is the most popular. Just a year or two ago, interventional endoscopy actually went into a formal match process. Previously, you just apply to all the programs in the country and you get interviewed, you get offers and pick one. Now, it's a formal match process. It's also expected that in the next couple of years, it will be a fully accredited ACGME fellowship just like interventional cardiology. If you didn't do the special training, you wouldn't be able to do certain procedures in GI. Currently, a lot of the older generation gastroenterologists still do ERCPs. Most of the younger people don't because they did numbers of them on their training of all GI fellows. So once it comes to full fellowship and board certification, it's expected that new trainees, if they don't do the actual training, won't be allowed to be allowed to do ERCP, EUS, and stents, and other interventional procedures. Interventional GI fellowships are pretty competitive as Sushil describes it. GI and cardiology balance it back and forth when it comes to post-medicine fellowships. "GI, number-wise, is the most competitive fellowship." When Sushil applied eight years ago, there were only about 30 program in the country. Now, it's close up to 75 with about 35,400 GI fellows graduating a year. So he reckons only 25% apply for the advanced interventional training. Although he wouldn't describe it as ultra-competitive but the majority of fellows he had trained that wanted to get it got in. Some may have to wait a year. But most fellows interested, eager, and did the right electives and the right types of research, got in. Sushil says you have to be focused and you need to take the right steps. Then there's a pretty good chance you're able to get into a spot. [16:37] What Makes a Competitive Applicant Sushil cites some qualities of a competitive applicant. He adds most interventional endoscopy directors look for people that have that extra knack (eye-hand coordination). Some of the hard skills are hard to train in one year. You need fellows that already have some experience. Moreover, you are gauged through letters from your program director and the number of procedures done during your general GI training. He adds it's important to consider who you want to hang out with for the whole year. "Unlike other fellowships, interventional fellowship is a one-fellow-a-year at any program." So it's basically just you and you're generally working with one to three core interventional endoscopy faculty. So you're spending a lot of time with just a couple of people. Compared to general GI training, you're rotating around different hospitals and different services. So you work with a number of faculty. This is different from interventional endoscopy training since you're only focused with one person or two. So who do you want to hang out with for a year? Lastly, be nice to them on your interviews. [18:30] Bias Against DOs and Working with Primary Care and Other Specialties Sushil had the opportunity to train alongside DO's throughout his career. There have been some who were awesome while there have been some who weren't so good. This is also true for MDs and just with any other specialty out there. But in terms of inherent institutional bias against DO's from the program directors, he doesn't think there is any. They don't look at it one way or another if a resident DO has gotten into general GI fellowship or interventional endoscopy. He adds that once you got to that level, you're met a lot of floors already. So he really doesn't think it's as relevant. Looking at interventional endoscopy fellows across the country, Sushil estimates that at least a third of them or maybe more are foreign grads. In terms of working with primary care physicians, Sushil explains how fellows complain all the time about nonsense or bogus consults. But because he thinks his career has been mostly private or quasi-private settings, his view has changed. "If a primary care or hospitalist called me, what I know and what they know are two different things." While he may see it as a simple question and answer and it's going to take him two seconds, they may see it as something more complicated. If you'd ask Sushil the protocols or the GNC7 or up to 9 in primary care, he would have a tough time treating hypertension diabetes. That's because he hasn't done it so long. Hence, he looks at it as something they don't do very often. They have a question. They need some help. So if a primary care physician has a question, the best thing to do is just call your local GI guy. Mostly, GI guys are laid back and not too uptight. His referral networks all have his number so they can always reach out to him whenever needed. As a specialist especially in GI (maybe more so in other fields), Sushil explains they're here to provide a service for them. They're here to do procedures and solve problems primary care physicians don't have the tools to solve. So when they call, help them out. Other specialties he works with the most are general GIs and surgeons for interventional endoscopy. They work a lot with specialty surgeons like biliary and colorectal as well as interventional radiologists. Things they can't take care of generally go to surgery. "That's where interventional GI has found its niche. It's at the interface between medicine and surgery." They don't cut on the surface or on the skin but they do almost all of their cutting inside. Sushil describes it as the next evolution from open surgery to laparoscopic to robotic. Now there's a new thing called NOTES (Natural Orifice Trans Endoscopic Surgery). They're doing surgical procedures through natural orifices. As a result, there is less incision time, and less recovery time. They're still trying to figure out where the interface is going to be. Whether it's surgeons doing these procedures or interventional GI guys or a radicalization of medicine surgery that are going to end up being guys that do these types of procedures. [23:57] The Most and Least Liked About His Specialty What Sushil knows now that he wished he knew back then is that anybody on their feet a lot for doing procedures have got to have very comfortable shoes. He wished he had bought a quality pair of shoes right after training. He went from one brand to another until just back to regular sneakers. What he likes the most about being an interventional endoscopist are procedures. He loves doing it. He loves the definitive nature of it. He likes that a patient comes in with a certain specific issue. And he's able to solve that issue most of the time. He likes to be able to give them definitive answer. What he likes the least is being oftentimes the first person to inform someone that they have cancer since they deal with a lot of GI oncology. Sushil explains it's very rare that an oncologist has to give someone a cancer diagnosis. Usually by the time they're going to an oncologist, diagnosis has been made. Unfortunately, they get a lot of referrals for lumps and bumps on a CT scan and they're the first one to have to break the news to the patient that they have cancer. No matter how many times he has done it, he feels terrible every time. Colon cancers are pretty terrible but a lot of stuff they do in interventional endoscopy is pancreatic, liver, and gallbladder cancers which are generally not so treatable. [27:00] New Changes in the Field of Interventional Endoscopy Sushil sees the field as having this continuous evolution. If you went in for a colonoscopy for whatever the reason and they found a four-centimeter polyp, they'd stop the procedure. They'd work the patient up. They'd give them a referral to go to see a colorectal surgeon. About ten to fifteen years ago, that changed. Gastroenterologists started doing advanced training, becoming interventional endoscopists. They started doing removing those polyps out themselves. It's relatively rare that a non-cancerous polyp in the colon is sent for surgical resection. It's relatively rare nowadays for a procedure called a PTC to be done. This was a procedure done routinely after cholecystectomy. The procedures they're starting to do now are coaching more and more on the surgical fields. Patients often went for surgery before for a lot of GI polyps and tumors, etc. A lot of that is now done more being minimally invasive that's being done by laparoscopic surgeons. But even more minimally invasive than that is where a GI guy comes in. "We're continually moving into this more and more non-invasive type procedures." A their technology is getting smaller and smaller, they're able to go into areas that thy were never able to go in before. Lastly, if he had to do it all over again, he still would have chosen the same thing. He enjoys GI and interventional endoscopy. He finds that it has the right blend of procedures but a little bit of continuity on the clinic side. He finds it as a good fit for him and what he enjoys. He doesn't think there's only one field a physician could go into but multiple fields. He thinks that people who enjoy the cerebral aspect of certain fields have a couple of different fields that would work for them. The same goes for those people that enjoy procedures. But all in all, Sushil has not complaints about the field he went into. [29:40] Final Words of Wisdom To those interested in going down this path, Sushil says it is never too early to start prepping your CV to get into GI. Consider that it's harder to get into GI given the numbers that is interventional endoscopy. When you start as an intern, go by the GI lab. Let the faculty know you're interested. Get involved. Get involved in research projects. They're not going to let an intern do that much. But there's always a need for someone to collect data, to collate data, to run statistics, to write papers. Get involved early on so that by the time you're second or third year role is around, you're seen as a junior fellow. You're part of the GI team. You're a resident but you're always hanging around the GI lab at any free time you have. "It is never too early to start prepping your CV to get into GI." Then when you move on to interventional endoscopy, the same thing. Go hang out with the interventional guys. Work on the papers with them. Come up with research proposals. Work on research projects, new ideas, new techniques. Be a junior interventional fellow. Links: MedEd Media Network