COMMENTARY

Gastroenterology: Engaging Your Mind and Your Hands

Perry Hookman, MD

Disclosures

March 15, 2011

When I was young, I loved reading detective stories. Among my favorite characters was Sherlock Holmes, who was modeled after a medical school professor. Later, as a medical student, this came into play as I tried to decide which field of medicine to choose as my specialty. I knew I liked internal medicine because it involved more detective work in making diagnoses and was more intellectually challenging than general surgery...or so I thought.

While training at Johns Hopkins Hospital as a first-year assistant resident in internal medicine, I still did not know which subspecialty I wanted to pursue. Then I received a call from my mother. Our family doctor had referred my father to a surgeon because he was having trouble swallowing, and tests showed an obstruction at the esophagogastric junction. The radiologist said it was probably cancer. My mother was extremely upset and wanted me to return home right away.

Instead, I proposed that my parents come to Baltimore so that we could get a second opinion from the chief of gastroenterology, Tom Hendrix, who had a special interest in esophageal disorders. I watched as Charles Siegel, senior fellow in gastroenterology, did an esophagoscopy on my father. Charlie used a rigid metal "sword-swallowing" esophagoscope modified from the old 1911 Jackson scope -- a much cruder device compared with today's flexible soft scopes. We saw a severe narrowing at the esophagogastric junction, but as Charlie pointed out, there was no mass.

The team then gave my dad an esophageal motility test, which was done in only a few medical centers at that time. It was a test for which Dr. Hendrix himself had been trained in Boston by a pioneer in the field of gastroenterology, Dr. Franz Ingelfinger. I observed with fascination as physicians inserted 3 nasal catheters that had been tied together with openings 5 cm apart. My father's esophageal pressure recordings showed flattened esophageal waves rather than the normal, progressive contractions with a high lower esophageal sphincter pressure. As it turned out, he did not have a malignant disease and he didn't have to undergo surgery to make that determination. Instead, the diagnostic procedures had revealed a benign disorder, achalasia. Esophageal dilation alleviated all his symptoms.

That was when I decided to pursue gastroenterology, realizing that it involved detective work and in many cases treatments that do not require a scalpel.

As you probably know, gastroenterology is a branch of internal medicine concerned with digestive diseases. Specialists in the field diagnose and treat a broad range of conditions -- everything from abdominal pain to esophageal reflux to jaundice. In addition, gastroenterologists often are consulted in cases of rectal bleeding or change in bowel habits when the diagnosis is unclear or where specialized diagnostic procedures are necessary. This may include diagnostic procedures such as blood tests, x-rays, or endoscopic examinations of the stomach or large intestine. Most gastroenterologists are certified by the American Board of Internal Medicine and then receive additional training in gastroenterology. To qualify for Board certification, a medical school graduate must complete an additional 4-6 years of specialty training in internal medicine and gastroenterology.

Gastroenterologists do not perform conventional scalpel surgery, but they do employ surgical procedures such as liver biopsies and endoscopic examinations of the esophagus, stomach, and small and large bowel. They also perform polypectomies and biopsies using surgical instruments that fit through a scope. In addition, these specialists work with surgeons to help select the best operation for a particular patient and to provide follow-up care for the individual's digestive disorder.

"Detective" technology has improved considerably since my father's treatment. Medicine and surgery will continue to embrace advances in noninvasive diagnostic and therapeutic tools, putting the gastroenterologist at the forefront of medical care. I would definitely recommend this specialty to students, especially those who enjoy both an intellectual challenge and the use of good eye-hand coordination.

Here I am, several decades later, happy to have chosen the specialty of gastroenterology as my life's work. And I've treated a lot of patients who are just like my father.

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