The hand-off
Article Outline
Training in endoscopy is fraught with frustration, especially when the instrument that we are trying to master is ripped from our hands. It is necessary to gain competency, although it is often accompanied by despair when the mentor takes over and completes the task. In this month's Fellows' Corner, Dr. Eric Cohen, an advanced hepatology fellow at Beth Israel Deaconess Medical Center in Boston, Massachusetts, shares his perspective on how to embrace and learn from this unavoidable aspect of learning endoscopy.
Juan Carlos Bucobo, MD
Fellows' Corner Editor
Interventional Endoscopy Fellow
Cedars-Sinai Medical Center
Los Angeles, California, USA
It is a curious procedural dynamic—that between the academic endoscopist and the fellow-in-training. Only one holds the tool at a time. In this respect, endoscopy is always a tug-of-war, albeit with variable force from the mentor's end of the rope. The dynamic shifts as the years of training wear on, and the fellow's grip tightens with repetition and experience. No measure of confidence, however, can prevent the occasional tortuous colon or peek-a-boo polyp, and this signals the imminent shift of power…the proverbial hand-off. Good effort…time's up. From the trainee's perspective, the hand-off is many things: a de facto measuring stick (sigmoid today, terminal ileum tomorrow), a release of frustration, a safety net, empathy for the patient.
Ostensibly, the hand-off is a mark of failure; that is, failure to complete the procedure. But, like all obstacles, it is also an opportunity. My father, the rheumatologist, reminds me time and again to take advantage of my years as a trainee, to never stop asking questions because there will come a day when that sounding board is gone. It is with this mind-set that the post–hand-off experience can reinforce the trainee's role. It is the ideal time to redirect focus and bolster a raw knowledge base.
An anecdote. I performed an EGD last month for the indication of varices surveillance on a 48-year-old patient with hepatitis C virus cirrhosis. In the mid-esophagus, there was a 1-cm smooth, pearly white indurated protuberance. My biopsy forceps slipped off the mass lesion on 3 consecutive attempts, and it was unclear whether the tissue that I obtained was adequate. Before a fourth attempt, my attending asked to “have a look,” euphemism for hand over that scope.
The fear, of course, was for neoplasia. We discussed the differential diagnosis. He showed me a new angle at which to approach the biopsy, and although his cold forceps slid like mine, his satisfaction with the biopsy sample taught me to recognize how much of a scrape is enough. We even summoned a nearby attending for a third opinion. The final pathology report days later of a granular cell tumor prompted additional discussion, additional reading, and increased satisfaction with the case. In lieu of losing interest and tuning out, this hand-off of the endoscope was just the beginning of an important experience.
According to analysis of a CORI (Clinical Outcomes Research Initiative) database, the reimbursement difference between private practice physicians and academic attending physicians and procedures involving fellows-in-training is estimated at a loss of $500,000 to $1,000,000 per year.1 This is directly correlated with the prolonged duration of a procedure that, in the same study, increased by 10% to 37% with fellow involvement. Thus, to make the payoff cost-effective in theory, the extra time spent can be time well spent if the intention to learn continues after the hand-off. In addition to this impetus to ask more questions and garner knowledge, it behooves the fellow to remain attentive for the patient's sake. Last year, Rogart et al2 from Yale University suggested that fellow involvement may increase adenoma detection rates during colonoscopy from 23% to 37% as well as increase the detection of more subtle adenomas. Whether this effect is nothing more than more efficient visual scanning by virtue of more eyes is irrelevant here.
Endoscopy can be frustrating, no doubt, and the requisite skill takes years to solidify, but this is also a reminder of the technicality and variability of this complex procedure, one that cannot be done by just anybody. The ego must be shelved and humility displayed. I say to the gastroenterology fellow-in-training: be eager to complete the procedure, be more eager once you cannot. From calloused thumbs comes wisdom.
Disclosure
The author disclosed no financial relationships relevant to this publication.
References
PII: S0016-5107(09)02734-5
doi:10.1016/j.gie.2009.11.010
© 2010 Published by Elsevier Inc.
