Author: Marc N. Katz

Posted on

How to Differentiate Pericardial and Pleural Effusions on Ultrasound/Echo

Although it is relatively easy to spot the difference between pericardial and pleural effusions on a chest x-ray, in medical training we have less exposure to ultrasound and it takes much more time to get comfortable looking at ultrasounds and knowing what you are looking at.

The first thing to remember with ultrasound and echocardiography is to get multiple windows! Just like any imaging study, ultrasound has its limitations. That’s why we try to squeeze our probe between or under the ribs in various areas of the chest to try and see the heart in different angles. An effusion can be obvious in one angle but be hiding in a different perspective.

This image below shows both a pericardial and pleural effusion. It’s one of my favorite images in the parasternal long (PSL) axis view via echocardiography. The quick and dirty way to tell if this fluid is a pericardial or pleural effusion is to find the descending aorta. The descending aorta is outside of the pericardium. It travels posterior to the heart down the chest. So when we see the heart in this PSL axis view we are cutting the aorta cross-sectionally. This should help bring you to identify the second important structure- the pericardium, or the connective tissue sac that the heart sits in. Knowing where these two structures are will allow you to more easily identify this fluid accurately as either a pericardial or pleural effusion.

View Image
Pericardial and pleural effusion

The second tip to correctly identify pericardial versus pleural effusions on ultrasound or echocardiography is to practice and get multiple windows! Getting multiple windows, or ultrasound view points of the heart, has the same importance in getting a 2-view chest x-ray. Multiple vantage points lets you better see the same structure from different angles and can help you clarify what you are looking at when it is not so obvious.

For further resources check out the following links I found helpful. A lot of these blogs are fantastic ultrasound information for individuals who want to dive deeper into echocardiography as well as ultrasound.

Subscribe! 
Posted on

Should You Take Supplements?

As a general cardiology fellow I discuss the risks and benefits of medications, diagnostic tests, and procedures with my patients everyday. Often I’m asked about unproven herbal remedies or over the counter (OTC) supplements. So let’s use a popular supplement used for cardiovascular disease to talk about supplements.

Supplements and the Food and Drug Administration (FDA)

The issue with these over the counter supplements is that they are not regulated by the FDA. When a drug is FDA approved it means it has generally gone through extensive testing to understand its safety and efficacy for specific indications. Drugs that are not proven to be efficacious or safe are not approved. FDA regulated medications also have quality control measures. It means that drug companies are required to prove that the drug you are taking is in fact of high quality and purity- that what you are prescribed is what you are actually taking. Conversely, non-FDA regulated supplements are not held to the same rigorous standards.

Here’s an example- red rice yeast

One example from the field of cardiology is the supplement known as red rice yeast. It is sold as a cholesterol lowering medication and as an alternative to prescription cholesterol lowering drugs. Red rice yeast contains monacolin K and is the active ingredient found in lovastatin that helps lower cholesterol levels. So it can in fact actually lower your cholesterol levels. However the quality and purity of the supplement is not nearly the same as that found in its prescription counterpart.

In 2017 a study from the European Journal of Preventative Cardiology researchers analyzed 28 brands of red yeast rice supplements to quantify their monacolin K content, the active cholesterol lower ingredient. To no surprise the authors found that ‘the strength and composition of red years rice supplements sold at mainstream retail stores in the United States remains unpredictable’ (1). In 2 brands no monacolin K was detected at all! In the 26 other brands the quantity of the active ingredient ranged from 0.09 to 5.48mg per 1200mg of red yeast rice. That’s a 60-fold range in quantity. Imagine being prescribed a medication and not knowing if you were getting 0.5mg or 5mg. Additionally if patients followed the manufacturers’ daily serving recommendations they could consume a range of monacolin K from 0.09 to 10.94mg- more than a 120-fold range in dosage (1). In summary, you don’t know how much of the medication you would actually be taking. Not only does this raise the question of the efficacy of the supplement but also its safety.

So should you be taking supplements at all?

Generally, if you are eating a well balanced diet you should not need to be taking supplements. A colorful diet rich in fruits and vegetables is the best natural supplement that you can take. For more information on healthy dietary choices and plant based diets check out two great handouts below created by cardiology fellow Dr. Danielle Belardo who hosts a nutrition podcast, blog, and cardiology clinic on plant based diets.

Okay but is it unsafe or unhealthy to use supplements?

At the end of the day the first thing you should do before you take any supplement is talk to your doctor. From a doctor’s perspective, we want to make sure that any supplement you take does not interact with medications you are currently taking and ensure that any supplement in question does not have serious side effects.

Conclusion

There are no magic pills. I’m always amazed that we know the most about the human body today than we ever did in human history but there still are no magic pills. As far as the medical field has come we still can’t cure every disease, ache, or ailment. Be extremely cautious about anyone selling a product with claims that sound too good to be true because they often are just that- not true. Supplements are a multibillion dollar industry and the last thing I would want to happen is for a patient not to be able to afford proven life prolonging medications because they were buying unproven and potentially dangerous or impure supplements.

Works Cited

  1. Cohen, P. A., Avula, B., & Khan, I. A. (2017). Variability in strength of red yeast rice supplements purchased from mainstream retailers. European Journal of Preventive Cardiology, 24(13), 1431–1434. https://doi.org/10.1177/2047487317715714
Subscribe! 
Posted on

Marijuana Use and Cardiovascular Disease

Marijuana Use and Cardiovascular Disease 🍃♥️

Yesterday was 4/20 so let’s take a look at a review article on marijuana’s effect on cardiovascular disease (CVD) published in the Journal of American College of Cardiolgoy in January 2020. Here are the highlights (no pun intended)

💔 Epidemiological studies have shown a temporal link between marijuana use and heart attacks. In 3,882 patients who had a heart attack, 3% smoked weed within the past year. 37 of that 3% smoked within 24 hours and 9 within 1 hour of suffering a heart attack, respectively

💓Abnormal heart rhythms, or arrhythmias, can occur with marijuana use. Weed can increase the heart rate and release catecholamines (adrenaline). One observational study of 2,459,856 marijuana users found 3% had arrhythmias- mostly atrial fibrillation (AF)

🧠 It has also been associated with increased stroke risk, peripheral artery disease, and cardiomyopathy (weak heart muscle)

💊 Weed (i.e. the marijuana) can also interact with medications by inhibiting the CYP 450 family

✅ Ultimately, observational studies suggest potential associations with marijuana use and CVD but lack robust levels of evidence. Hence I am weary of anyone who touts marijuana or CBD as a miracle cure for anything. It may have specific uses but with regard to CVD the jury is out. We need more robust studies but few randomized control trials (RCT) have or will likely occur due to its Schedule I federal drug designation as a controlled substance and a general lack of homogeneity of the drug itself

🔑 Patients at high-risk of CVD should avoid or minimize marijuana use

To view the original journal article click here: http://www.onlinejacc.org/content/accj/75/3/320.full.pdf?download=true

Subscribe! 
Posted on

General Medicine | how to talk to your family about code status

In medicine we colloquially say someone ‘codes’ if their heart stops requiring cardiopulmonary resuscitation (CPR) or if they can’t breath on their own requiring intubation. So ‘code status’ refers to the level of medical interventions a patient wishes to have if their heart or breathing stops. Unfortunately the worst time to discuss something as important as you or your loved one’s code status is when a patient is in critical condition requiring life saving measures. The COVID-19 pandemic is the perfect opportunity to talk to your doctor and loved ones about your code status. Here’s some basic information about code status, how I talk to my patients about it, and how you can talk to your family so you’re all on the same page.

Main categories of code status

There are generally two main categories. The first is ‘full code’ which generally means to perform all life saving measures. We will perform CPR and intubate. The second main category is ‘DNR/DNI’ which stands for ‘do not resuscitate/do not intubate’. So when we say ‘DNR’ we generally mean ‘do not perform CPR’ and when we say ‘DNI’ we generally mean ‘do not place the patient on a ventilator’.

These two terms, DNR and DNI, are separate but interconnected entities. If your heart stops beating then you are technically dead and, as such, will need a ventilator to help you breath too. However if you stop breathing or are having trouble breathing requiring you to be intubated your heart very well may continue to beat on its own. This can happen for a number of reasons, including COVID-19. However even just explaining this situation breads multiple different variables and gets us bogged down in the weeds. For now, let’s focus on intubation since this is more important to understand than ever during the COVID-19 pandemic.

Misconseptions

Before I go any further I want to address one of the most common misconceptions with regard to code status that I have observed in my short career in medicine. Just because someone is DNR/DNI it does not mean that we stop treating the patient. If they are sick, have an infection, or are in pain we continue to treat those issues. Being DNR/DNI is not the same thing as withdrawing or stopping care.

Why does someone need to be intubated?

Generally we intubate patients if they cannot breath on their own. This can happen in a number of clinical scenarios. In COVID-19 we are seeing that patients who have increasing oxygen requirements often deteriorate quickly. Meaning they go from needing a little bit of oxygen via a nasal cannula to potentially being intubated within a day. Sometimes we choose to intubate patients in a controlled setting when a patient is getting worse before the

How long do patients stay intubated?

It depends. It depends on each clinical situation and the reason for intubation. In COVID-19 some patients have required 2 weeks of ventilator support and others are able to be extubated much quicker.

So why would anyone choose to be DNI?

This is the crux of the code status discussion. Generally, people who are more sick with more comobidities (greater number of other medical health problems) have more difficulty being extubated successfully. They have trouble regaining the strength to breath. If someone cannot be successfully extubated the options are limited to tracheostomy (an incision in the neck where the ventilator can then be connected to) or terminal extubation (we remove the breathing tube anticipating that the patient won’t be able to breath on their own and will ultimately die).

Clinically with regard to severe illnesses like COVID-19, intubation is only one piece of the overall puzzle. A patient can be successfully intubated but still have a long battle ahead of them and intubation does not guarantee that they will survive. It is impossible to know with 100% certainty which patients will be intubated, improve, and be extubated, which patients will be intubated and unfortunately still pass away, and which will be intubated and have difficulty breathing on their own again.

Changing the terminolgy

Professionally speaking I don’t like using the term ‘DNI’. I prefer the term ‘allow natural death to occur’ because that is precisely what we are doing when we choose not to intubate someone who needs it.

End of life care

Again, just because someone is ‘DNR/DNI’ does not mean we do not treat their symptoms or other illnesses. In any illness when a patient might require intubation but they choose to allow natural death to occur by avoiding intubation we change our clinical focus to other aspects of a patients care. I’ve been at bedside with families whose loved ones are DNR/DNI after a long battle with cancer or other diseases and don’t want to prolong their suffering any longer. It’s not an easy decision to make at first but one that is so much easier to make when everyone in a family knows the patients wishes.

How can you talk to your family and/or doctor about your code status?

If you have the time I highly recommend reading Atul Gawande’s Being Mortal. It’s an amazing book about death and dying in the United States and he puts it more eloquently than I ever could.

When I talk to patients about code status most common delineation they are able to make is if (1) they would want to be intubated no matter what and all life saving measures performed or (2) that they would not want to be intubated if they did not have a good chance at surviving with a good quality of life. Notice I said ‘survive with a good quality of life’ and not just ‘survive’. This is an important distinction.

What would a good quality of life look like to you? This might seem abstract but it helps doctors guide their medical decisions if we can understand what is important to you. What makes you happy on a day to day basis? What would be a quality of life and what would not be worth living? It means that code status is not always cut and dry. Its not black or white but instead shaded with areas of grey. It also illustrates how important it is to have this type of conversation not only with your family but also with your doctor. So I encourage you to please talk to your physician about you or your loved one’s code status the next time you can with your physician.

I know this is not an easy conversation. The first time I talked to a patient about their code status they literally asked me point blank ‘is this the first time you’ve talked to someone about this?’. So if you want to start the conversation about code status with your family about your or their code status you can use the following script to get the ball rolling.

“I want to talk about your/my code status. This is difficult to talk about but it is important to know what you/I would want done in the unfortunate event that your/my heart would stop beating or if you/I would stop breathing on our own.”

Conclusion

I have seen patients die surrounded by loving family members at bedside who disagreed with their loved one’s decision but respected it and made the patient’s last days or hours occur with less pain and suffering. I’ve also seen the opposite.

This is by no means an exhaustive conversation about code status but please talk to your doctor and family members about your and their code status. Additionally, make sure everyone in the family knows their wishes and not just a few people as it is far more difficult to make these tough decisions when some family members are left out of the loop of communication.

Subscribe! 
Posted on

Medications After a Heart Attack| Why Dual Anti Platelet Therapy Is So Important

When you have a heart attack, or a myocardial infarction (MI), one of the most common outcomes is the placement of a stent inside your coronary arteries, or the arteries that supply the heart itself. The most common type of stent we use today are drug eluting stents (DES). Two medications cardiologists routinely prescribe together after DES placement are dual anti platelet therapy (DAPT).

DAPT is composed of two medications. The first is aspirin and the second is either Plavix (Clopidogrel), Brilinta (Ticagrelor), or Effient (Prasugrel). They are supremely important after a having a stent placed in the heart because they keep the stent open. DAPT keeps stents open by preventing clots from forming inside the stents.

The history behind coronary stents starts several decades ago when balloon angiography was the only direct mechanism we had to combat sudden heart attacks. We used to insert a balloon inside the clogged artery and open it up. However this only worked for a short period of time and at 6 months the artery was often narrowed again almost 50% of the time. Additionally when we deflated the balloon the natural physiology and physics of the balloon angiography would cause the artery to recoil and often would be even more narrow than before. This is visualized below on the left hand side

Elastic recoil and neointimal hyperplasia after stent placement

That’s why bare metal stents were created. The metal inside a stent kept the artery wall from recoiling. However these stents also closed up with time. The reason they closed or narrowed over time was due to neointimal hyperplasia. Neointimal hyperplasia is shown above on the right hand side. It is the process of normal smooth muscle cells inside of the coronary arteries abnormally being deposited inside the inner layer of the artery wall. That’s why drug eluting stents (DES) were created.

DES are the same metal stents but they are coated in a drug that slowly seeps into the artery wall and prevents neointimal hyperplasia and thus prevents the slow narrowing of the artery from happening. However this causes the metal struts of the stent itself to be exposed to the bloodstream for a longer period of time and results in an increased risk of in-stent thrombosis- or clots to form inside the stent. This is where dual anti platelet therapy (DAPT) comes in. DAPT keeps stents from having clots form inside the stent itself.

In the video below I go into greater detail about what happens during a heart attack inside the coronary arteries, a brief history on how heart attacks previously used to be treated, why we developed new types of coronary stents, and ultimately the importance of taking your dual anti platelet therapy after a heart attack and stent placement, and possible side effects of the medications to watch out for I also briefly explain the duration of DAPT therapy, side effects patients should look out for, other medications to avoid after a heart attack, and I stress the importance of never stopping your medications without first talking with your cardiologist.

Dual Anti Platelet Therapy After Myocardial Infarction and Coronary Stenting

***This video is intended for educational purposes only. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard or read online***

Subscribe! 
Posted on

Hahnemann University Hospital Closure Saga Continues: ex-residents & fellows likely forced to purchase their own tail end medical malpractice insurance

In June I completed my three year internal medicine residency at Hahnemann University Hospital/Drexel University College of Medicine. In July the hospital, recently sold to new owners, shut its doors.

I wasn’t impacted directly. However active residents and fellows, including first year residents starting the first month of training who moved their lives and families, were forced to find new residency programs. Our program leadership were incredibly supportive and helped these residents and fellows find new hospitals to finish their training. We thought it was in the rear view. It was stressful but it was over. We got out. Turns out that was just chapter one.

Last week our Program Director (PD) informed us that the current owners of the hospital would likely not be covering our tail end medical malpractice insurance. It will likely cost a few hundred to a few thousand dollars depending on the duration of malpractice needed. It can be much more expensive for other fields like OB/GYN or emergency medicine. You can see the full email sent from our PD in my tweet below.

You might be wondering how this is legal given it is detailed in our contract that they have to cover tail end malpractice insurance. Well, it isn’t but they’re doing it anyway. You also might be wondering what tail end medical malpractice insurance is and until a week ago I didn’t know either as I detailed in my Instagram post below.

View this post on Instagram

The #HahnemannClosure saga continues 😡 Remember Hahnemann? It was that teaching hospital that closed its doors and orphaned over 400 residents and fellows this past July. Well, this week we learned that the owners of the hospital plan to break their contractual obligations and force us to pay for tail end malpractice insurance ▪️ You might be wondering ‘what’s tail end malpractice insurance’ and to be honest until this week I had no idea! It’s basically malpractice for when you no longer work at a hospital to cover you in case you are named in a lawsuit ▪️ Wanna know why I didn’t know what it was till this week? BECAUSE RESIDENTS AND FELLOWS AREN’T SUPPOSED TO BUY THEIR OWN MALPRACTICE INSURANCE. This is unheard of and can cost thousands of dollars for each individual. Or we can go uninsured and risk litigation where we can potentially lose a whole lot more. Not to mention attorney fees😡 ▪️ #HahnemannClosure has already impacted a population of doctors in training that have been through enough adversity and a decade’s worth of stress. And I haven’t really been impacted much until now. And now. I. Am. Pissed. 😡😡 ▪️ So what can you do to help? Send me funny cat videos. Just kidding (but not really) 1️⃣ If you live in Philly, contact your congressman. This should never happen again. It shouldn’t even be a question of if it’s possible. It should be outright illegal. No resident or fellow should ever have to be in doubt of their future because of the possibility of having to buy their own malpractice insurance while in training 2️⃣ Spread the word. I’m thankful that I was interviewed by @whyy and even @zdoggmd made a video about us! Unfortunately though we need more help. Maybe if enough people yell someone will hear us. So if you know anyone who can help spread the word please share the #HahnemannClosureSaga story and send them my way. Because enough is enough. 🎤drop.

A post shared by Marc Katz, MD (@kittykatzmd) on

I spoke with Whyy Philadelphia who went into further detail in the article below. They were also able to speak with Dr. Aizenberg, Hahnemann’s venerable former Internal medicine program director.

Former Hahnemann residents fear bankruptcy will leave them without malpractice insurance


Former Hahnemann residents and fellows impacted by this are organizing. In the meantime, we await a final ruling to decide our fate. Unfortunately as Dr. Aizenberg outlined in his email it doesn’t look like the situation will result in a favorable ruling for former Hahnemann residents. Even if a decision is made to have our former employer follow through with their obligations outlined in our contracts it won’t happen for quite some time down the line. This leaves residents to foot the bill. Yet another out of pocket expense that many can’t afford and further stress on an already heavily burdened group of doctors in training.

A broken healthcare system failed the patients of Philadelphia and now continue to fail it’s doctors. One of my favorite social media doctors, ZDoggMD spoke about Hahnemann in one of his most recent video posts, below.

ZDoggMD on continued Hahnemann closure issues

Many people have pointed for assistance or guidance from medical residency training oversight boards like the ACGME. Unfortunately this likely won’t be a quick fix with a linear projection. At this time we have not been told of any further developing communication from them or any other medical boards.

Ultimately I’m thankful that I got lucky. I was on vacation during the last week of residency when I found out Hahnemann was closing it’s doors. This is the first time I’m directly impacted by its closure. For many of my colleagues from Hahnemann however this is yet another impediment to their future.

Current third year residents need to find jobs and can be uniquely impacted by this issue. You need tail end malpractice insurance to work. I am no expert in malpractice or physician contracts but I’m told that some hospitals simply won’t hire you if you don’t have it. They’re going to be forced to buy it. Others are seeking fellowship positions and this issue will certainly carry on with them wherever they match. I hope that fellowship programs view ex-Hahnemann residents like I do- with respect and admiration for not just persevering through these challenges but thriving despite them.

Some of my prior colleagues and I didn’t always see eye-to-eye. It happens when you have, shall we say, a ‘strong personality’. But to my ex-Hahnemann colleagues I promise to continue to advocate for you and use my platform to spread awareness of this developing situation. We share a common bond and unfortunately we are the last group of residents that will ever know the meaning and depth behind the phrase ‘welcome to Hahnemann’.

People wonder why the medical field is going through an epidemic of professional burnout. This developing story embodies the issue. We are viewed as expendable and nothing more than part of the bottom line and treated like it. Not all hospital systems run like this and I hope that this will become an exception to the rule but only time will tell.

So what can you do to help? Share this story. First comes awareness. Next comes action.

Subscribe! 
Posted on

YouTube Channel

I just started a new YouTube channel! My first three videos are on Caribbean med schools, why I chose to pursue an internal medicine residency, and how to get a cardiology fellowship and become a cardiologist in the US. Watch them below and be sure to subscribe! The next videos coming out will be patient centered about heart health!





Subscribe! 
Posted on

Personalized Advising

Getting into residency isn’t easy and medical students are often left to figure out the roadmap to residency on their own. In the past I’ve given out general advice for free but with increasing numbers of people who message me I’ve been spread thin and haven’t been able to provide the highest quality personalized advice that each medical students needs. That’s why I’ve started an hourly advising service. Anyone can read my blog posts but sometimes you need a personalized touch and that’s what I want to give to you. For a small fee I will make your application to residency in the United States a priority. By signing up for my personalized advising services you get to talk with me and get personalized advice on how to build your roadmap to residency and improve your chances of matching in the specialty of your dreams.

I know firsthand how expensive medical school is and I don’t want to bleed medical students dry. That’s why I balance affordable and customizable fees and services. Here’s what I offer:

Application analysis

  • Fee: $100
  • One hour session via cell phone

You went to medical school to become a doctor. Getting a residency position is how you get there. Unfortunately not everyone matches into a residency position. In 2018 only 52% of US international medical graduates matched into residency. With my guidance you will have a clearer understanding of what a strong application looks like and will be able to traverse medical school and the residency application process with confidence.

Personal Statement Review

  • Fee: $225
  • 30 minute advising session
  • 2 revisions of your personal statement

Personal statements are one of the most difficult parts of the application process. Most people don’t enjoy writing and have difficulty putting their emotions onto paper. Furthermore, a good personal statement should keep your application on par but a bad one can sink you. Working with me will give you clarity on how to write a stellar personal statement and help you get a residency position.

Interview Prep

  • Fee: $325
  • Two hour interview advising session
  • One online practice mock interview with feedback

For medical students actively applying for residency, the interview is the last step in securing your future career. Acing the interview will leave a strong lasting impression on each residency program you interview with and help you secure a residency position. In contrast, a bad interview can secure you a post-interview rejection. Work with me to understand how to properly answer the most common interview questions and help you ace the interview to get the residency of your dreams.

Interested? E-mail me at MarcKatzMD@gmail.com to get started!

Posted on

Top Blog Posts for Medical Students

I recently came back from a trip to Barbados where I gave the incoming first semester class of Ross University some advice on how to succeed in med school. Here’s a summary of my top med school blog posts broken up into various categories:

Med School Study Tips

Med School Study Resources

USMLE resources

Clinical Rotations

Should You Go To a Caribbean Med School

Discusses the discrepancy in the match rate between US-IMG’s and US MD and DO graduates

Residency Tips for Med Students

Residency Tips for Residents

Ross University Specific

Interviews with Residents in Various Specialties

Interview with Fellows in Various Specialties

Posted on

How To Match Into Gastroenterology Fellowship

I’m excited to share my next interview. Keerthi Shah was a senior resident at my residency program and is now a first year gastroenterology fellow at Hahnemann University Hospital/Drexel University College of Medicine.

Thanks for letting me pick your brain Keerthi. Can you tell my followers a little bit about yourself?

I would love to! I’m a PGY-4 or a first year Gastroenterology (GI) Fellow at Drexel University College of Medicine.

I grew up in Georgia most of my life. I went to Georgia Technology for undergrad and then Philadelphia College of Osteopathic Medicine for medical school (the GA campus). When I’m not practicing medicine I love to dance and travel. I’ve been learning, teaching and performing kuchipudi, an indian artform, since I was 7!

I’ll start off with another softball question and take you back to your residency days. Why did you go into medicine?

I was always pretty sure that I wanted to do medicine and then specialize. Combining patient histories with objective data to figure out the diagnosis was like a puzzle. I liked that kind of challenge. In addition, having such a broad knowledge base prepares you for any future fellowship.

Did you always know that you wanted to go into GI?

No! I was between nephrology and gastroenterology when I started residency. These two fields are worlds apart!

The biggest reason I found my way to GI is the procedures. There is such a satisfying feeling about working with your hands and learning a new technical skill. Even during my time in medicine, I enjoyed placing central lines and performing paracentesis. I knew the learning curve would be very steep, but I was ready for that challenge!

To be extra sure of this path I spent months exploring gastroenterology and hepatology, both inpatient and outpatient. All this time just made me more sure and excited.

GI fellowship is three years. What are the subspecialties in GI and how long are they?

There are 5 main subspecialities in GI: (1) motility and functional GI disease, (2) Inflammatory Bowel Disease, (3) advanced endoscopy, (4) nutrition/obesity and (5) hepatology/transplant hepatology. You can choose to do an extra year or you can attend symposia and workshops to build those skills. You essentially don’t have to do the extra year to be able to practice most of those subspecialities. The only exception is advanced endoscopy and trnsplant hepatology which is 2 years and 1 year respectively.

Do you think you will stay as a general gastroenterologist or do you plan on pursuing a subspecialty?

I’m fortunate to be at a program that exposes fellows to subspecialities. Honestly, I’m just enjoying learning about every area of GI. Motility, nutrition, and IBD are areas of focus that I’ve particularly enjoyed. For right now though, I plan to stay general gastroenterology.

I remember you telling me about a pretty alarming turn of events during interview season that almost left you without a fellowship. What happened and what lesson should fellowship applicants take away from it?

I’ll start out saying I’m an osteopathic physician. When I was applying, I applied to both MD and DO programs. Some of the DO programs are still outside of the match process. I interviewed and got accepted at one program. After a lot of thought, I accepted the position and cancelled the rest of my interviews. A couple days before the match, the program contacted me saying they could no longer give me the position because of internal issues. I scrambled to get interviews back. Luckily everything worked out and I matched at my home program. Needless to say, this was a stressful couple of days! The moral of the story is to not cancel anything till the contract is signed.

Gastroenterology is one of the most competitive internal medicine fellowships. What are the most important aspects of a GI fellowship application?

Great letters of recommendation, which stems from good mentorship, are the most important part of your fellowship application. Take the time to get to know the GI attendings at your home program. Work in the inpatient and outpatient clinics.. Get letters from these physicians! Their names are known in the GI community and getting a great recommendation will go a long way.

Research is a must for competitive fellowships like gastroenterology; however quality is valued over quantity. Programs like to see that you took a project to completion from conception to poster/oral presentations and eventually to publication.

Lastly, work hard! People will notice your hustle and that will make your LOR’s even better.

What research did you do during residency?

My first project was assessing quality of life (QOL) in transplant recipients and the use of group experiences to improve QOL. I was fortunate to be able to present this at an international conference and very recently published in Pediatric Transplantation Journal.

I did mostly hepatology research because my first mentor at Drexel was Dr. Santiago Munoz. The two notable projects were addressing etiology and prevention of hyponatremia in cirrhosis at an inner city hospital and expanding inclusion criteria for Obeticholic Acid in Primary Biliary Cirrhosis. Both projects were presented at GI conferences.

From there I expanded to gastroenterology. I worked with our Motility focused attending on evaluating Dysynergic Defecation with 3D High Resolution Anorectal Manometry.

Did you do any quality improvement projects?  

I did one quality improvement project analyzing and improving night float and nursing communication using cell phones and text paging. The current pager system is such an archaic interface for communication. Our hospital is now transitioning to a phone based night float system.

What general advice do you have for prospective residents who want to pursue gastroenterology?

Spend time getting to know the GI program at your hospital. Work with them inpatient and outpatient. Do research with them.

The hardest part of fellowship is the volume of consults and learning a new technical skill. Hard work and a good attitude will go a long way.

You recently started a blog. Tell me about it. What’s your vision for your blog?

I recently started this blog initially to answer questions from my friends and family. I wanted to be able to provide them with answers that were based on up to date literature.

Our interactions with patients in the clinic are so brief. In 15 minutes, we are expected to take a history, diagnose, and treat. This leaves patients’ with a lot of questions and they seek their answers on social media. I wanted to be a part of the social media dialogue. I also wanted this to be my way of supplementing abbreviated clinic time to explain gastroenterology topics to patients in an effective way.

Where can my followers find you on Instagram? What can the expect to see?

@digestivedoc

In a nutshell, my Instagram is a combination of 3 things: GI, travel and friends/family. When it comes to gastroenterology I hope to perpetuate evidence based information as well as tips and tricks for aspiring GI fellows.

What’s the weirdest question people ask you after they find out you’re a GI fellow?

Honestly nothing weird! People ask me a lot of questions regarding their bowel movements. I think the strangest part of being a fellow is the number of pictures of stool I have on my phone.

How much poop is too much poop?

Well, everyone’s “normal” is different! Too much poop for you might be someone’s normal! The number of times you go isn’t as important as the consistency of your bowel movements. If you’re having 3 or more loose/watery Bristol 5-6 bowel movements, we need to talk!

Why do you get the day after drinking diarrhea?

Acute alcohol consumption inhibits absorption of nutrients and fluids. this stimulates secretion of water and electrolytes. effect of alcohol on CNS increases colonic motility and transit time. This prevents absorption of water in the large intestine. If you are drinking sugary mixed drinks, you might be drinking sugar substitutes, which causes osmotic diarrhea.

A patient recently asked me about constipation. What are some common home remedies patients can try?

Constipation affects so many people and results in many hospital admissions. Some things people can do at home include exercise, fiber supplementation, answer nature’s call, and improve your stooling posture. Osteopathic Manipulative Medicine (OMM) can also be helpful. Check out my blog post for more details!

Thank you so much for sharing some insight into the world of gastroenterology Keerthi. As always be sure to subscribe below so you don’t miss out on the next post!

Subscribe!