My entry into the field of nutrition support
Entering a fellowship in gastroenterology should be pursued with an open mind. We all have varying experiences in the management of patients with gastrointestinal conditions, both in the inpatient and outpatient arenas through residency training. My early experiences in fellowship at the University of Chicago centered on the management of patients with inflammatory bowel disease (IBD) and with research interests related to the clinical course of IBD. I was also fortunate to be part of a fellowship program offering both level 1 and level 2 training with a longstanding track record of graduating fellows responsible for the running of NSTs at their local institutions. Categorical fellows spend 3 months of training on a rotation with combined inpatient and outpatient responsibilities focusing on the management of patients with intestinal failure, inpatient management of complications from PN support, and an outpatient clinic focused on small-bowel disorders (celiac disease, small-bowel bleeding, and intestinal malabsorption). This experience led me to pursue level 2 training at Northwestern University with a combined focus on small-bowel diseases and enteroscopy.
These collective experiences in fellowship and postfellowship training grounded my ideas on the role of nutrition pervading many gastrointestinal conditions from acute and chronic pancreatitis and IBD to rare conditions such as enteropathy associated with immune deficiencies and autoimmune enteropathy. Now, as a junior faculty member with a focus in nutrition support and small-bowel disorders, my clinical responsibilities include a dedicated half-day in the management of outpatients (parenteral and enteral nutrition), inpatient rounding with our dedicated NST focusing on the initiation of PN, management of home PN complications, and dedicated procedural time focusing on enteral access techniques (percutaneous gastrostomy/jejunostomy tubes) and small-bowel enteroscopy. To my surprise, entry into the field of nutrition support and small-bowel disorders has been filled with excitement and a growing list of collaborations and opportunities. While initial work in the management of PN has been in existence since the 1970s and earlier with respect to the development of safe administration techniques, most of my current work transcends specialties as we develop appropriateness criteria related to PN support in collaboration with a wide range of specialties that include surgery, oncology, and palliative care.
Seeking opportunities for additional training
As the field of gastroenterology grows outward in various directions, mastery of subjects has led to subspecialization in specific areas including interventional gastroenterology, pancreatology, IBD, and motility disorders. The field is primed for broader access to specialty training in nutrition support and small-bowel disorders. Exposure to dedicated training in nutrition and nutrition-related disorders is vital as part of a categorical fellowship, but can also be complemented via visiting observerships, access to formal level 2 training programs, and external programs related to promoting nutrition education.
Since 2001, formal nutrition fellowship programs offering level 2 training have been compiled by the National Board of Physician Nutrition Specialists, although attraction of interested fellows has been lacking.2 The Nestlé Nutrition Institute Clinical Nutrition Fellowship, endorsed by the American Society for Parenteral and Enteral Nutrition and the AGA, is an ongoing program that pairs interested trainees with expert program faculty through onsite clinical rotations lasting a total of 4 weeks.2 Attendance at national and international conferences can supplement a fellows training in nutrition, and an increased focus on nutrition lectures should be a priority of meeting education committees to increase the exposure of trainees to leaders in the field.
Conclusion
A career in nutrition support and small-bowel disorders is incredibly rewarding as it incorporates the basic physiologic processes of digestion and absorption with a wide array of pathologic conditions. Incorporation of the basic principles of intestinal absorption allows for a greater understanding of the role of the low–fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in the management of irritable bowel syndrome to the varying principles of diets currently under study for the management of IBD. Outside of this spectrum, working with an NST allows for the management of complex cases of malnutrition resulting from disorders ranging from cancer to various postsurgical intestinal alterations. Although observerships and external training programs allow for an introduction into the field, formal level 2 training, combining both work with a NST and small-bowel enteroscopy, allows for exposure to the full range of disorders of the small bowel. As patients continue to seek disease management options rooted in diet, the demand for gastroenterologists with subspecialty training in nutritional disorders will continue to grow and will require further support across training programs to incorporate additional training into categorical fellowships.
References
1. Daley BJ et al. JPEN J Paren Enteral Nutr. 2016;40(1):95-9. doi: 10.1177/0148607115571155.
2. Kiraly LN et al. Nutr Clin Pract. 2014;29(3):332-7. doi: 10.1177/0884533614525212.
3. Hu J et al. Nutr Clin Pract. 2018 Apr;33(2):191-7. doi: 10.1177/0884533617700852.
4. Scolapio JS et al. J Clin Gastroenterol. 2008 Feb;42(2):122-7. doi: 10.1097/MCG.0b013e3181595b6a.
5. American Association for the Study of Liver Diseases et al. The Gastroenterology Core Curriculum, 3rd ed. Gastroenterology. 2007;132(5):2012-8. doi: 10.1053/j.gastro.2007.03.079.
Dr. Micic is assistant professor of medicine, department of internal medicine, section of gastroenterology, hepatology, and nutrition, University of Chicago.
