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Certificate of added qualification for hepatology: Vindication not vanity
Comment From the Editors Certificate of Added Qualification for Hepatology: Vindication Not Vanity
T
he American Board of Internal Medicine will offer the first certifying examination for the Certificate of Added Qualification (CAQ) for Transplant Hepatology in 2006. Most recognize that the field of transplant hepatology has developed dramatically during the past 2 decades to such a degree that there is a divergence of skill sets required by primary gastroenterologists and those who further specialize in the care of individuals with liver disease, particularly in the setting of liver transplantation. Refined immunosuppressant strategies, living-related donor liver transplantation, and prevention and management of recurrent viral hepatitis are just a few of the novel and continually evolving issues facing transplant hepatologists. The CAQ seeks to address a perceived deficiency in the training of hepatologists; there are no fellowship programs that are accredited by the Accreditation Council on Graduate Medical Education (ACGME) and no uniform curricula that must be followed. After a lengthy process, initiated by the American Association for the Study of Liver Diseases, transplant hepatology will be recognized as a distinct discipline by the American Board of Internal Medicine and the American Board of Medical Specialties. The first certifying examination, slated for 2006, will encompass management of end-stage liver disease; pretransplant and peritransplant management; and, to a lesser degree, transplant immunology. Board-certified gastroenterologists who spend significant time treating pre- and posttransplant patients would be eligible to sit for the first 3 examinations. After 2012, only individuals with at least 1 year of training in an ACGME-accredited hepatology fellowship will be eligible for the CAQ. The American Association for the Study of Liver Diseases should be applauded for its dedication to developing a CAQ with the goal of maintaining
the highest standards for patient care. Intuitively, requiring demonstration of proficiency in a highly specialized, dynamic field such as transplant hepatology, and eventually mandating training at a certified hepatology program, will lead to better outcomes. Nevertheless, there may be a few challenges ahead as the CAQ is implemented. Many current transplant hepatologists received varying degrees of specialized hepatology training during fellowship. Survival data after liver transplantation, according to United Network for Organ Sharing, would suggest that the multidisciplinary teams of health care professionals, including transplant hepatologists, who treat these complex patients before and after liver transplantation, are providing excellent care. These outcomes are a testament to new strategies in patient selection, prioritization, and management of pre-, peri,- and posttransplant medical and surgical issues. Ironically, these same individuals who were instrumental in these outcomes and advances would be prohibited from taking the CAQ-certifying examination after 2012 (once the “grandfathering” clause expires) because none were trained in ACGME-accredited programs. Are there enough training slots to meet future needs? It seems every liver transplant program is trying to recruit more hepatology faculty to meet increased clinical demands. After 2012, CAQ will only be available to those who completed an additional year of training in a certified transplant hepatology program. A quick count of fellowship programs in the US indicates that there are currently about 13 programs offering dedicated hepatology fellowships, with a total of approximately 31 positions, and none of these are accredited by the ACGME. Although ad hoc guidelines for hepatology training programs were published in 2002 by a subcommittee of the American Society of Transplantation, it is unknown whether current programs are or will remain in compliance with future directives. As regulation increases, the enthusiasm for maintaining a training program may diminish, particularly if no additional funding
mechanisms are available to accomplish the new mandates for training and oversight that will be required for ACGME accreditation. Additional innovative ACGME-accredited programs will hopefully be opened to meet these demands. Focusing transplant hepatology training on those enrolled in specialized CAQ-oriented programs has the potential to erode hepatology training for general gastroenterology fellows. Clinical rotations on the hepatology service, integrated into many gastrointestinal training programs, are limited, and dedicated transplant hepatology fellows may receive priority for the evaluation and treatment of pre- and posttransplant patients. Occasionally, this decreased exposure to the rewards of academic hepatology could be a decisive factor in diverting some individuals away from the practice of transplant hepatology. Once the CAQ is established as the standard for patients listed for or after liver transplantation, there is the potential for non-CAQ gastroenterologists to become hesitant to assist the transplant center in treating these complex patients within their communities, possibly for medicolegal reasons. Indeed, my current practice is to encourage the continued involvement of the patient’s community gastroenterologist while the patient is listed for liver transplant. We must be careful not to alienate community health care providers as members of the patient care team. Again, if the supply of CAQcertified hepatologists does not increase to meet the demand, the availability of patient care within the community may be limited. The CAQ is an important step to maintain the highest standards for the treatment of patients with end-stage liver disease before and after liver transplantation. With more regulation comes more responsibility, and the hepatology community will face additional challenges as the CAQ is implemented.
MICHAEL W. FRIED Associate Editor doi:10.1053/j.gastro.2005.02.052 GASTROENTEROLOGY 2005;128:817
T
he American Board of Internal Medicine will offer the first certifying examination for the Certificate of Added Qualification (CAQ) for Transplant Hepatology in 2006. Most recognize that the field of transplant hepatology has developed dramatically during the past 2 decades to such a degree that there is a divergence of skill sets required by primary gastroenterologists and those who further specialize in the care of individuals with liver disease, particularly in the setting of liver transplantation. Refined immunosuppressant strategies, living-related donor liver transplantation, and prevention and management of recurrent viral hepatitis are just a few of the novel and continually evolving issues facing transplant hepatologists. The CAQ seeks to address a perceived deficiency in the training of hepatologists; there are no fellowship programs that are accredited by the Accreditation Council on Graduate Medical Education (ACGME) and no uniform curricula that must be followed. After a lengthy process, initiated by the American Association for the Study of Liver Diseases, transplant hepatology will be recognized as a distinct discipline by the American Board of Internal Medicine and the American Board of Medical Specialties. The first certifying examination, slated for 2006, will encompass management of end-stage liver disease; pretransplant and peritransplant management; and, to a lesser degree, transplant immunology. Board-certified gastroenterologists who spend significant time treating pre- and posttransplant patients would be eligible to sit for the first 3 examinations. After 2012, only individuals with at least 1 year of training in an ACGME-accredited hepatology fellowship will be eligible for the CAQ. The American Association for the Study of Liver Diseases should be applauded for its dedication to developing a CAQ with the goal of maintaining
the highest standards for patient care. Intuitively, requiring demonstration of proficiency in a highly specialized, dynamic field such as transplant hepatology, and eventually mandating training at a certified hepatology program, will lead to better outcomes. Nevertheless, there may be a few challenges ahead as the CAQ is implemented. Many current transplant hepatologists received varying degrees of specialized hepatology training during fellowship. Survival data after liver transplantation, according to United Network for Organ Sharing, would suggest that the multidisciplinary teams of health care professionals, including transplant hepatologists, who treat these complex patients before and after liver transplantation, are providing excellent care. These outcomes are a testament to new strategies in patient selection, prioritization, and management of pre-, peri,- and posttransplant medical and surgical issues. Ironically, these same individuals who were instrumental in these outcomes and advances would be prohibited from taking the CAQ-certifying examination after 2012 (once the “grandfathering” clause expires) because none were trained in ACGME-accredited programs. Are there enough training slots to meet future needs? It seems every liver transplant program is trying to recruit more hepatology faculty to meet increased clinical demands. After 2012, CAQ will only be available to those who completed an additional year of training in a certified transplant hepatology program. A quick count of fellowship programs in the US indicates that there are currently about 13 programs offering dedicated hepatology fellowships, with a total of approximately 31 positions, and none of these are accredited by the ACGME. Although ad hoc guidelines for hepatology training programs were published in 2002 by a subcommittee of the American Society of Transplantation, it is unknown whether current programs are or will remain in compliance with future directives. As regulation increases, the enthusiasm for maintaining a training program may diminish, particularly if no additional funding
mechanisms are available to accomplish the new mandates for training and oversight that will be required for ACGME accreditation. Additional innovative ACGME-accredited programs will hopefully be opened to meet these demands. Focusing transplant hepatology training on those enrolled in specialized CAQ-oriented programs has the potential to erode hepatology training for general gastroenterology fellows. Clinical rotations on the hepatology service, integrated into many gastrointestinal training programs, are limited, and dedicated transplant hepatology fellows may receive priority for the evaluation and treatment of pre- and posttransplant patients. Occasionally, this decreased exposure to the rewards of academic hepatology could be a decisive factor in diverting some individuals away from the practice of transplant hepatology. Once the CAQ is established as the standard for patients listed for or after liver transplantation, there is the potential for non-CAQ gastroenterologists to become hesitant to assist the transplant center in treating these complex patients within their communities, possibly for medicolegal reasons. Indeed, my current practice is to encourage the continued involvement of the patient’s community gastroenterologist while the patient is listed for liver transplant. We must be careful not to alienate community health care providers as members of the patient care team. Again, if the supply of CAQcertified hepatologists does not increase to meet the demand, the availability of patient care within the community may be limited. The CAQ is an important step to maintain the highest standards for the treatment of patients with end-stage liver disease before and after liver transplantation. With more regulation comes more responsibility, and the hepatology community will face additional challenges as the CAQ is implemented.
MICHAEL W. FRIED Associate Editor doi:10.1053/j.gastro.2005.02.052 GASTROENTEROLOGY 2005;128:817