Gastroenterology
Volume 145, Issue 6 , Pages 1182-1185, December 2013
published online 21 October 2013.
John Del Valle, Section Editor
Hepatology is a discipline that has developed substantially over the past 3 decades, from one that featured many diagnoses but very few therapeutic interventions to a specialty in which we can effectively prevent and treat many liver diseases. Several therapeutic interventions for the complications of end-stage liver disease were well-described and considered standard of care, but had not been proven to be of benefit. Patients with liver disease were assigned to a variety of causes of their liver disease, but little could be done to improve their lifestyle or prevent morbidity and mortality. Liver transplantation, for instance, was still in its infancy. Other patients were correctly labeled as having inflammation of the liver and the term hepatitis was widely used. However, the exact cause of the hepatitis could not be established and hence a beneficial treatment could not be established. Fortunately, over the past 20–30 years hepatology has become a field of medicine where we can provide accurate diagnoses, beneficial treatment, and, more important, prevention of end-stage liver disease. Despite this increase in knowledge and efficiency in our medical care, the training of physicians with expertise to provide these services has not kept pace with the rapid expansion of our medical knowledge.1 In fact, more than 10 years ago, hepatology was viewed only as a subset of the vast field of gastroenterology.
Is There a Demand for Hepatologists?
As we made advances in the diagnosis and treatment of liver diseases, it became apparent that the field of hepatology would grow. It also became clear that manpower needs would dictate the need for physicians with special expertise to provide adequate patient care. For gastroenterology trainees, an important date was July 1, 2001, when the Medicare colon cancer screening benefit was expanded to include screening colonoscopy for average risk individuals once every 10 years. As this economic incentive became widely established, hepatology quickly became a field of specialization which was less desirable for fellows.
The American Association for the Study of Liver Diseases (AASLD) represents the largest group of physicians interested in hepatology. In 2013 the society had >4000 dues-paying members. However, only about half of these physicians are based in the United States.2 Furthermore, only a few of these AASLD members indicated that their practice focuses on hepatology ≥50% of the time. Interestingly, most AASLD members in the United States are associated with an academic appointment at a teaching hospital and have their practice within a system with a liver transplant program. In 2013, there were 138 adult and pediatric liver transplant programs registered with United Network for Organ Sharing.3 There is a clear demand for hepatologists to join these transplant programs. However, many of these openings are unfilled. This is because the supplying of physicians with the required expertise in hepatology has not kept pace with the growing demand.
History of Certification of Expertise in Hepatology
According to the membership survey of the AASLD, most current hepatologists did a fellowship in gastroenterology in which hepatology was emphasized.3 This was a personal choice of the trainee, because no specialized program existed for training in hepatology. In the mid to late 1990s, AASLD leadership commissioned a task force to determine whether hepatology was a distinct and separate entity within the field of gastroenterology. The consensus was that advanced and transplant hepatology not only had its own body of specialized knowledge and expertise, but that practicing gastroenterologists often did not consider themselves adequately prepared to care for patients with end-stage liver disease. The task force reported that most referrals to liver transplant centers and consult requests to transplant hepatologists came from gastroenterologists, not from primary care physicians, surgeons, or internists.
In 2000, the AASLD applied to the American Board of Internal Medicine (ABIM) to consider a certifying examination in transplant hepatology.4 The AASLD argued that advanced and transplant hepatology was clearly a distinct discipline, separate from gastroenterology; that there was a distinct body of literature which was devoted exclusively to the discipline; and that practicing gastroenterologists viewed certain colleagues as having unique expertise in hepatology.4
After some debate, the application was supported and the ABIM created a certifying examination, which was ready for its first administration in November 2006. This initial examination was taken by 214 ABIM-certified adult gastroenterologists. The pass rate was 88% and the minimum passing score was to answer 73% of the 175 questions correctly.4 After looking through various test validation statistics, the ABIM concluded the examination had performed as expected.5
By 2013, only 430 physicians have become board certified in transplant hepatology.6 Most of these candidates took the examination in the first year that it was offered because candidates' clinical experience was “grandfathered” in. Qualifying to take the transplant hepatology boards now requires specific clinical training in advanced and transplant hepatology.
Hepatology Training Pathways
In the last 10 years, 3 pathways existed for physicians to become trained in hepatology. The first is a 1-year training program not associated with a GI training program and was not recognized by the Accreditation Council for Graduate Medical Education (ACGME). The second pathway is through an ACGME-recognized 1-year program, also separate from a GI training program. The third and most recent is an innovative pilot program that combines shortened training with new tools of medical education assessment. This last program is closely identified with a GI training program.
Advanced and Transplant Hepatology Not Associated With Gastroenterology Training
An option that became popular in the late 1990s and early 2000s was an “isolated” fellowship devoted exclusively to advanced and transplant hepatology. These programs typically were not associated with gastroenterology training programs. They were often populated by internal medicine residents who saw the competition for traditional gastroenterology fellowships increasing and used this avenue to enhance their candidacy. In addition, many non-US graduates saw this as a way to improve their chances at either getting a residency or a gastroenterology fellowship.
These programs were typically 1-year positions with no established curriculum and had no formal recognition process. The AASLD provided support for many of these trainees in the form of competitive grants based on an institution's record of training physicians in liver disease. However, retrospectively, many of the young physicians who were supported in these programs did not turn out to be hepatologists. It is not clear how many succeeded in obtaining a gastroenterology fellowship. The author's personal experience suggests that a small minority of trainees who did this type of hepatology fellowship actually stayed in the practice of hepatology.
Many of these “isolated” hepatology training programs are now defunct. The reasons for this include their ambiguous curriculum, difficulty finding funding to provide salary support, and a lack of recognition by either the ABIM or by the ACGME.7
Advanced and Transplant Hepatology Training After Training in Gastroenterology
In 2006, the ACGME allowed the creation of advanced and transplant hepatology training programs. Initial enthusiasm was high and many academic centers submitted the application paperwork to create hepatology training programs at their institutions (5).5 These programs require the hepatology training be done after completing gastroenterology training. Thus, a potential hepatologist selecting this route had the disadvantage of training 3 years in internal medicine, 3 years in gastroenterology, and then 1 additional year in hepatology. In addition, this route requires (by definition) that the hepatologist compete to get into a gastroenterology training program. In addition, the requirements for ABIM certification in transplant hepatology require that all candidates be board certified in gastroenterology. Thus, the requirements of the ACGME (for programs) and the ABIM (for individuals) have definitely lengthened and complicated the process of training hepatologists.
Under the current policy, the only way to become a credentialed hepatologist is to complete a 3-year fellowship in gastroenterology, complete an additional 1-year fellowship in advanced and transplant hepatology, and then pass the ABIM examinations in both gastroenterology and transplant hepatology.
However, it became clear that the ACGME and ABIM rules governing these programs discouraged trainees from entering this pathway. Currently, the ACGME website lists 39 programs that have a transplant hepatology fellowship. However, there are only 34 fellows enrolled for the 2013–2014 academic year.8 Given that many programs are approved for 2 fellows per year, these numbers reflect that the current paradigm for hepatology training is not succeeding in attracting hepatology trainees.
ABIM Pilot Program: Advanced and Transplant Hepatology Training “During” Training in Gastroenterology
In 2012, the AASLD, with the input of other GI professional societies, worked with the ABIM to create a 3-year, combined GI/transplant hepatology training program. The initial goal was to create a training program that recognized and promoted the unique manpower needs in advanced and transplant hepatology. As mentioned, many of the “standard” transplant fellowship were not attracting applicants. Training directors created the template of a competency-based training program that combined training in gastroenterology as well as transplant hepatology. The training in gastroenterology per the ABIM suggestions would be assessed by the traditional standards of medical education, which existed in 2012, and the specifically developed tools of competency-based medicine education would be applied to the transplant hepatology year. This pilot program became available on July 1, 2012.6
The transplant hepatology pilot program sponsored by the AASLD and approved by the ABIM has several goals. The first was to be a front runner in medical education by deriving and implementing a competency-based training program using milestones and entrustable professional activities (EPAs).9 Milestones and EPAs are relatively new concepts in postgraduate medical training. Milestones are a series of developmental goals related to the current competencies, which are designed to help assess whether an individual trainee has met the competency. EPAs are concrete clinical activities that link to core competencies or milestones. They are designed to incorporate the professional judgment of competence by seasoned clinicians. As the trainee progresses through his education, the goal is to allow the trainee to build a collection (portfolio) of EPAs to document competence. Additional information for the internal medicine milestones is available online.9A second goal was to create a program that allowed trainees to sit for both gastroenterology and the transplant hepatology ABIM board examinations after they had successfully completed only 3 years of clinical training. A third goal was to produce 5–10 additional board-eligible transplant hepatologists each year.
Competency-Based Medical Education Innovations
Following the new medical education goals of the ACGME, the transplant hepatology pilot program used EPAs to assess trainees. The supervising and oversight committee of the AASLD also developed a transplant hepatology in-service examination that will be made available to all programs participating in the pilot. Finally, competency-based medical education requires care transition measures, multisource feedback instruments, milestones, and performance measures.
Details of Incorporating the Pilot Program Into an Existing Gastroenterology Training Program
The professional societies involved in training gastroenterologists and hepatologists did not wish to do increase competition for internal medicine residents to get into training slots. The pilot program must have an existing, traditional, ACGME-accredited transplant hepatology program. They also must have an ACGME-accredited gastroenterology program. The candidate must apply to his gastroenterology and transplant hepatology program directors, and should be judged to be competent in GI by the end of year 2 and on a trajectory to successfully complete GI training by the end of 3 years. Obviously, cooperation must exist between the gastroenterology and transplant hepatology training programs to ensure that there is sufficient volume of hepatology clinical opportunities both for the gastroenterology trainees as well as the hepatology pilot fellow. Some adjustment may be may be needed to ensure adequate manpower to cover the gastroenterology services, especially those that are not related to hepatology, such as advanced endoscopy, inflammatory bowel disease, and motility. The oversight committee felt that the transplant hepatology pilot fellows in many ways should still have similar duties to what they would have been during their third year of gastroenterology training. Specifically, the oversight committee felt that the training pilot fellow should continue in their continuity clinic, continue to perform standard endoscopies, participate in educational programs such as conferences, biopsy review, and morbidity and mortality conferences, and still take after-hours calls.
The process of identifying and approving candidates for this pilot program has been kept as simple as possible. The candidate fellow should be identified no later than the middle of the second year of training. Early identification is important to ensure that the fellow is on the “right trajectory” with regard to his/her GI clinical skills. Approval is needed from the candidate's institution Graduate Medical Education authority, typically the designated institutional official. Because the institution must have ACGME-approved transplant hepatology and gastroenterology fellowships, the candidate must get written approval from both program directors. A letter of intent is then sent to the AASLD Transplant Hepatology Pilot Program Steering Committee. If the institution and the candidate are approved, the committee recommends to the ABIM that the candidate be allowed to sit for the transplant hepatology boards after completion of 3 years of clinical training and after passing the gastroenterology boards. Current policy is that the ABIM must have documentation of the candidate's successful gastroenterology examination before the candidate will be allowed to sit for the transplant hepatology boards. This may change in the future, because there is some concern about a candidate's inability to prepare for and take both board examinations simultaneously.
Current Participation in Pilot Program
The pilot program is in its second year. In 2012–2103), there were 4 fellows. In 2013–2014, 3 fellows are participating.10 A total of 7 programs have joined in the pilot program effort. Candidates interested in pursuing a standard 4th-year transplant hepatology fellowship or the new pilot program should contact both the GI training program and the transplant hepatology directors at the institution of their choice. Additional information is available on the AASLD website.11 A specific letter written in May 2012 to all GI and transplant hepatology training program directors is available at this website. Overall feedback from program directors, both transplant hepatology and gastroenterology, has been positive.
Summary
The tremendous advances in clinical hepatology are a great success story in the practice of internal medicine. Hepatology has now evolved from an observational medical science to one that has a myriad of interventions, ranging from improved diagnostics, preventive strategies, and antiviral therapies, and, of course, liver transplantation. Therapies for viral hepatitis and liver cancer as well as the care of patients with end-stage liver disease have become increasingly complex. Care of patients with liver disease requires the special expertise of dedicated physicians. However, our training programs designed to developing physicians with this expertise have not kept pace with the medical advances. In fact, the length of the required hepatology training has been increased. Multiple barriers have been placed between internal medicine residents who are interested in hepatology and their career goal of being recognized as a hepatology expert.
Current training in transplant hepatology requires the candidate to successfully complete a traditional 3 year fellowship in gastroenterology. There are now 39 transplant hepatology programs accredited by the ACGME but these programs are having difficulty filling their training slots. The lack of success in attracting potential hepatologists is due to the competiveness of getting into gastroenterology programs, the 7 years required of post graduate training and the financial burden of perpetual training.
Under the leadership of the AASLD, the ABIM has approved a pilot program to train hepatologists that seeks to circumvent these pitfalls. Under special circumstances, candidates can complete their clinical training in both gastroenterology and hepatology in 3 years. They will be eligible to sit for the gastroenterology boards and if successful in passing the GI board examination, can sit for the transplant hepatology boards. Institutional programs and individual candidates for this pilot program are carefully selected by an AASLD committee that also has oversight into ensuring that the pilot program is innovative in its medical education. Pilot programs will utilize EPAs, newly developed milestones, a recently created transplant hepatology in-service examination, and will be monitored by many novel feedback instruments.
In summary, the growing need for physicians with an expertise in advanced and transplant hepatology has necessitated a change in our paradigm on how we train hepatologists. The future of hepatology has never looked brighter and the AASLD and its partners are committed to providing innovative educational and training avenues as we enter a new era in the world of liver diseases.
Conflicts of interest The author discloses no conflicts.
PII: S0016-5085(13)01497-2
doi:10.1053/j.gastro.2013.10.023
© 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.
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