Report by Tom Lee October 2013
About a year ago I completed an application form for the inaugural NREG Mayo Clinic Fellowship sponsored by Cook medical. The opportunity to spend time at the most famous hospital in the world, watching internationally renowned endoscopists at work, was irresistible.
Now I`m on a British Airways flight to Chicago en route to Rochester, Minnesota. I`ve heard a lot about the Mayo clinic over the years. Is it true there are traffic lights in the operating theatres to aid patient flow? Is it really the largest hospital campus in the world? Do the hotels that surround the hospital really have covered, heated walkways directly onto the wards? Why on earth would anyone want to start a working day with a pre-breakfast meeting at 630am?
Jet lag results in waking at 5am. There`s a thunderstorm outside. Fortunately, as predicted, despite my hotel being 5 blocks away from the main hospital building, I can get there through the covered walkways without going outside.
After checking in with Education Administration as a visiting clinician I get a brief tour of the main buildings from Mary, the coordinator for the Developmental Endoscopy Unit. We then head off to the main endoscopy suite in the Gonda Building, one of three units across the site. 9 rooms running from 730am to 5pm, mainly complex and therapeutic work. I spend the day with Dr Gostout, the professor who is sponsoring my time here. He strikes an impressive figure, long white ponytail, trimmed white beard, confident and unquestioning in his ability to fix most problems with an endoscope. In addition, he`s an incredible warm and welcoming person who made me feel very welcome throughout.
First impressions of the unit: the ethos is all about excellence and patient safety. Turn around time between patients is slow but this is because most patients are anaesthetised, and the endless checklists take a lot of time.
Unusual sights of the day:
1. A band playing in the cafeteria at lunchtime to entertain patients and visitors.
2. The main foyer full of staff mingling and chatting at 4pm in the afternoon because it was an`ice cream social`- an event run weekly by the Staff Appreciation service: Come to the foyer, have an icecream on us, listen to a brass band and mingle with your fellow Mayo workers.
Some adjustment required to get into the American fashion of starting endoscopy lists before 8am- doesn`t come naturally. Retracing my route from yesterday back to the office on the 8th floor of the Gonda building is challenging- the place is massive. I briefly end up in a large waiting room for the Neurology outpatient department- it`s all nice carpets, wood panelled walls, leather sofas, computers for public use. Another wrong turn and I`m in a clinical looking corridor with 12 EEG rooms lined up down one side.
I`m directed to the endoscopy unit at St Mary`s Hospital- one of the two inpatient units on the campus. It`s about a mile away across town with about 1400 beds. I spend the day with one of the senior endoscopists watching him perform complex procedures including a couple of ERCPs, some EUS, some feeding tube placement and a couple of bleeding cases. I realise that, whilst it`s interesting to watch leading-edge endoscopy being performed, what I took away from today was what can be learnt from watching a leading-edge endoscopist at work. He was measured and calm, extremely knowledgeable and technically excellent. The most impressive aspect was how he made the endoscopy room work for him.
Day 6- Monday
Spend the day in the Developmental Endoscopy Unit (DEU) - an area used for developing new endoscopic techniques. During the day I watch Ray Sarmiento, Prof Gostout`s research fellow, demonstrating ESD. This included extending the procedure to full thickness excision and defect closure using an over the scope suture device. This was one of the highlights of the trip- seeing cutting edge techniques in development.
Back at the Mayo in the afternoon, I watch Louis Wong Kee Song, one of the associate professors and a leading therapeutic endoscopist, perform EMR on a duodenal adenoma and resect a small colonic cancer for palliation, closing the inevitable defect with 2 Ovesco clips.
Day 7- Tuesday
Back in the DEU I get to practice ESD using a new technique with balloon dissection of the submucosal space. Enric Brullet, a visiting Spanish endoscopy consultant assisted and oversewed the defect using an over-the-scope suturing device.
Spend the afternoon with Wong Kee Song watching colonoscopy and double balloon enteroscopy. Meet with the Cook Haemostasis Product Manager for an update on Hemospray which is taking longer to enter widespread use in the USA due to the regulatory processes.
Day 8- Wednesday
Full day on ‘Gonda 2’- the main therapeutic endoscopy unit. Mainly with Louis Wong Kee Song. His working week consists of all day complex therapeutic endoscopy, no outpatients, no inpatients, no general medicine, just complex endoscopy after complex endoscopy. Watch a couple of double balloon endoscopies- they do about 15 a week here.
Look around the main ambulatory endoscopy unit on the 9th floor- this one has 26 rooms with 10-15 on the go at any time- this is where the bread and butter stuff is done. Attend the GI Grand Round presented by Dr Katz from the oesophageal interest group on swallowing problems and diaphragmatic breathing for symptoms such as reflux and aerophagia, something he clearly spends a lot of his time thinking about.
During the afternoon I meet with Dr Sedlack, another associate Professor– he has an interest in endoscopy training and use of simulators. Mayo trainees have to do 20 procedures on the simulator before touching a scope in a patient- seems sensible but expensive.
Day 9- Thursday
Back on Gonda 2- watch a 5 and a half hour ESD of an ulcerated gastric lipoma-initially raised with EUS guidance. Left half way through to go the GI grand rounds- a lecture by Seth Sweetster on serrated polyps. They`re doing a lot of basic science work on the serrated pathway and are firmly of the opinion that anything that isn`t normal colonic mucosa should be removed. Back down to watch the end of the ESD with involved closing the gastric defect with an overstitch. Later in the afternoon I went to St Mary`s with Wong Kee Song after a spot of lunch in the Charlton staff canteen. He attempted a pull down gastropexy on a volved hiatus hernia. Observed Dr Goustout training a fellow to perform colonoscopy. Dinner at City café with some of the endoscopy staff where I was presented with a Mayo Clinic Tie.
Day 10- Friday
Watch an EMR with Dr Wong Kee Song then go upstairs to Gonda 9 – The ambulatory area with around 20-30 rooms running at once. Observe some routine diagnostic colonoscopy- different approach to sedation here- deep conscious sedation with a starting dose of 5mg midazolam administered by a nurse sedationist. Interesting discussion with the lead consultant for endoscopy quality assurance about their QA mechanisms and patient pathways. Spend a little time with Dr Wong Kee Song doing DBE then with Dr Goustout doing a single balloon ERCP. As full time endoscopists they become familiar with their equipment and what they can achieve therapeutically in a way that we can only aspire to.
My experience at the Mayo Clinic widened my appreciation of what endoscopy can achieve and the future potential of newer techniques. It will be fascinating to see how the innovative techniques I saw in the Developmental Endoscopy Unit will translate into routine clinical practice.
I am very grateful to Prof Gostout and his staff, in particular Ray Sarmiento and Louis Wong Kee Song for their time, teaching and hospitality. I am also grateful to Cook and NREG for supporting the fellowship.
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With Professor Gostout
Outside the Mayo with Dr Ray Sarmiento