Gastroenterology & Endoscopy News
ISSUE: OCTOBER 2011 VOLUME: 62:10
Could Condensed Training Remedy Shortfall of Hepatologists?
Ten years ago, the American Board of Internal Medicine (ABIM)—after much debate—approved the designation of advanced/transplant hepatology as a distinct discipline. Backed by every major gastroenterology and liver society in the country, the specialty was created to reverse a shortage of trained hepatology professionals who were faced with growing numbers of transplant patients.
Now, as the specialty enters its second decade, its proponents once again are looking at ways to revamp training. They say new training paradigms are needed to raise the number of trained liver specialists capable of managing an increasing burden of disease that ranges from obesity-related disorders to patients on transplant lists.
“Training hepatologists is a really big issue now because the burden of liver disease in America is accelerating, and I believe is outstripping the supply of trained individuals to manage it,” said Carl L. Berg, MD, chief of gastroenterology and hepatology, and medical director of liver transplantation at the University of Virginia in Charlottesville.
Most experts point to three factors driving the crunch on hepatology services: growing numbers of patients with liver disease; markedly improved and complex therapies, which have lengthened the lifespan of those with severe disease; and no corresponding rise in the number of physicians with specialized training to care for these patients.
“There are millions of Americans with chronic liver disease, which remains clinically silent until advanced liver disease sets in,” noted Arun J. Sanyal, MD, president of the American Association for the Study of Liver Diseases (AASLD), in the organization’s monthly newsletter last year (available at www.aasld.org/news/archive/022510/Pages/default.aspx). “On the other hand, there are only a thousand or so fully trained hepatologists to serve our communities.
“If progress is to be made in eradication of liver disease and promotion of liver wellness, fixing this manpower shortage must become a national priority,” Dr. Sanyal wrote.
Additionally, the Institute of Medicine called attention to the shortage in January 2010, in a report that highlighted a marked lack of awareness, knowledge and skills among the general medical workforce regarding liver disease.
Although crude forms of hepatology have been around since 2,000 BC (when fortune tellers examined animal livers to foretell the future), modern clinical hepatology has been around for only about 60 years.
The first liver association, the AASLD, was founded in 1950, with its inaugural meeting attended by 12 individuals. Nine years later, British physician Sheila Sherlock set up a liver center at Royal Free Hospital in London, the first of its kind worldwide. For the next 40 years, hepatology fell firmly within the specialty of gastroenterology.
After 1990, liver transplant centers proliferated, and with them, transplant patients. As a result, there was a growing need for dedicated hepatologists to care for these complex patients. In 1999, AASLD members acknowledged the need, saying that advanced/transplant hepatology should be a “distinct discipline” and more physicians trained in the field were necessary.
The emphasis in the new specialty was on liver transplantation rather than broad hepatology, said Bruce R. Bacon, MD, professor of internal medicine at Saint Louis University School of Medicine in St. Louis, in a published interview (Can J Gastroenterol 2007;21:421).
“It was thought that general hepatology remained within the purview of gastroenterology,” Dr. Bacon explained.
Since then, however, the thinking has changed.
“At the present time, it has become increasingly apparent that hepatology should be considered a distinct discipline independent from, but closely allied with, gastroenterology,” Dr. Bacon said.
Today, many millions of Americans have liver disease, but the exact figure is unknown. An estimated 4.5 million Americans are infected with hepatitis B and C viruses. Many millions more are affected by non-alcoholic fatty liver disease, although the true incidence remains undetermined; the American Liver Foundation estimates it may be as high as 25% of the adult population. Additionally, an undetermined number of Americans are living with transplanted livers. Today, 6,000 people annually undergo liver transplants, while another 16,000 are on the waiting list.
Compare that to the numbers of liver specialists: About 3,376 specialists in 2007 were dues-paying members of the AASLD. Of them, only half are American-based physicians and only half of those consider the AASLD to be their primary professional society affiliation.
Because the hepatology certification exam has been offered only three times since its creation in 2004, most gastroenterologists who look after liver patients are not board-certified. In fact, only about 2% of practicing gastroenterologists have transplant hepatology certification (Elta GH. Am J Gastroenterol 2011;106:395-397).
Today, 31 accredited hepatology training programs exist in the United States, most of which train only one or two fellows per year. Of these, only 30 to 40 positions are filled annually, said John R. Lake, MD, professor of surgery and medicine, and director of the liver transplant program at the University of Minnesota, in Minneapolis. The remaining spots remain vacant.
For gastroenterology fellows, the reluctance to pursue additional hepatology training can be understandable. Hepatology training adds an extra year, after six years of internal medicine and gastroenterology. Moreover, hepatology work generally pays less than an endoscopy-based gastroenterology practice. The patients require more time, more counseling and undergo fewer procedures.
In the long term, hepatology can be a more taxing specialty for many physicians, said Vinod Rustgi, MD, clinical professor of medicine and surgery at Georgetown University Medical Center in Fairfax, Va.
“It’s very different from procedure-based gastroenterology. Hepatologists end up having to talk to their patients much more than gastroenterologists. It’s a different way of spending the day—you have to interact closely with people,” he said.
Even if gastroenterologists are committed to treating liver disease patients, there’s no real need to pursue the subspecialty certification—they can practice hepatology without pursuing the additional year of training. And no difference exists between what gastroenterologists and hepatologists can do. Both groups perform a full breadth of procedures and their practices often overlap. Nothing would preclude an expertly trained gastroenterologist with hepatology instruction from focusing his or her practice on liver disease patients. The sole exception is directors of liver transplant programs, who require very specific training in hepatology. “But that only applies to 100 people around the country,” said Dr. Berg.
Janice Jou, MD, now a hepatology fellow at Duke University, in Durham, N.C., chose to do the additional year of fellowship to become board-certified. At the time she applied, the fellowship was an easy choice. She was awarded a grant from the AASLD, which made the additional year more financially viable. She loves the patients, their complexity and acuity.
“The advice given to me was [a hepatology fellowship] is what I should do,” said Dr. Jou.
Now, however, she sometimes wonders if she made the right choice. “It’s hard to weigh the delayed gratification of doing another year of fellowship,” she said.
She adds, however, that she believes people who are pursuing an academic career should do the transplant hepatology fellowship. “I do think it is evolving and is likely to change. However, in the current climate I think that if you are serious about an academic career, it is important. This is one of the main reasons that I chose to do the extra year, as I am interested in staying in academics.”
Revamping the Program
There’s no question that the United States needs more trained physicians to treat liver patients. Ironically, it’s the same situation that the gastroenterology community hoped to address a decade ago, with the creation of the advanced/transplant hepatology fellowship and board examination. Now, again, the gastroenterology and liver societies are looking at ways to close the gap between the number of patients who need liver care and the providers available.
Hepatologists by the Numbers
3,444 the number of dues-paying members in the AASLD in 2010
2,335 the number of AASLD members who reside in the United States
1,689 the number of “regular” AASLD members, defined as any physician, scientist or researcher working in the United States, Canada or Mexico who has contributed to knowledge about the liver or biliary tract
31 the number of U.S. programs offering an advanced/transplant hepatology fellowship
30-40 the approximate number of positions filled in advanced/transplant hepatology fellowship programs annually in the United States
7 the number of years of postgraduate training currently required to become a board-certified advanced/transplant hepatologist
4 the number of fellowship grants provided by the AASLD
3 the number of times that the Transplant Hepatology Certification exam has been offered
AASLD, American Association for the Study of Liver Diseases Sources: AASLD News, February 2010; AASLD staff
In 2009, a multisociety task force on gastroenterology training made a number of recommendations on the future of gastroenterology and hepatology training (Am J Gastroenterol 2009;104:2659-2663). Among the recommendations were the creation of a competency-based curriculum, condensed training for transplant hepatologists and enhanced disease-specific training. The ABIM recently gave the go-ahead on the first of those recommendations. This winter, the board approved a pilot program that will test a competency-based curriculum and competency-based assessment program for gastroenterology and hepatology. Trainees will be tested for technical and cognitive milestones through their procedural training, which could effectively short-track their training.
This type of competency-based training is expected to expand over the coming years, said Dr. Lake. The Accreditation Council for Graduate Medical Education (ACGME) already requires residents to demonstrate competency in six core areas. Additionally, similar competency-based programs are being tested around the world in fields outside of gastroenterology. Canadian orthopedic surgeons are testing and implementing a system based on 281 competencies deemed to be of importance in the training of orthopedic surgeons (Wadey VM et al. J Bone Joint Surg Br 2009;91:1618-1622).
Discussions are ongoing to find further ways of condensing the training process for transplant hepatologists. The task force suggested that transplant hepatology training could occur during the standard three-year fellowship, with a tailored exam at the completion of training. Since 1996, gastroenterologists were allowed to subspecialize in areas other than hepatology within their three-year fellowship at certain programs, by tracking elective and research time toward their subspecialty.
“Instead of doing three years of gastroenterology and one year of hepatology, you might be able to customize your three-year program in a way where you would do roughly two years of general gastroenterology and in the final year do full-time hepatology,” said Dr. Berg.
One other option may be to allow hepatologists to train directly after internal medicine and bypass the need for training in gastroenterology. Preliminary discussions were held with the AASLD and ABIM several years ago, but the concept remains theoretical.
All experts who spoke with Gastroenterology & Endoscopy News agreed that hepatologists will never become the sole providers in liver care. “There’s simply not enough of us,” said Dr. Berg.
As liver care becomes more complicated, extra training and expertise will become important for management of some of the problems, he said. But, he added, “I still believe fundamentally that we are going to need our general gastroenterology colleagues to help us because the burden of disease is so great.
“Because the epidemic of obesity in this country—which is associated with fatty liver disease—is so great, that burden is going to just skyrocket over the course of the next decade,” said Dr. Berg.