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Third-tier fellowship training in hepatology: advantages and program selection
THE FELLOWS’ CORNER
Third-tier fellowship training in hepatology: advantages and program selection As the practice of hepatology becomes increasingly complex, many fellows are opting for additional training. This month our guest author, Dr. Meena Bansal, discusses the benefits of obtaining advanced training in hepatology, as well as issues to consider when choosing a program. Kevin J. Peifer, MD Fellows’ Corner Associate Editor Fellow Division of Gastroenterology Washington University St. Louis, Missouri, USA By the time GI fellows reach the end of their fellowship, the prospect of yet another year of training – which typically follows 6 years of residency and fellowship – can be daunting. The decision to take on this additional year is a personal one and can best be focused around the question: ‘‘Where am I now, and where do I want to go with my career?’’ In truth, given the opportunities to customize training within a GI fellowship, this question might be best raised at the outset of the fellowship. Quite simply, if a GI trainee expects to practice transplant hepatology in an academic center or to serve as the ‘‘resident hepatologist’’ as part of a larger community-based gastroenterology group, the answer is clear: an additional year of transplant hepatology is strongly advised. However, the answer is less clear if you simply wish to be comfortable managing patients with acute and chronic liver disease, as well as end-stage liver disease before transplantation. In this case, your decision depends on the quality of your GI fellowship – in particular, how much exposure you had to managing patients with liver disease. For example, GI fellows at Mount Sinai rotate on the liver transplant service for 3 months during their second fellowship year and participate in the liver continuity clinic throughout the fellowship. If, however, a fellow expresses a specific interest in liver disease, he or she may spend additional time on the liver service during the third year. If your program offers this kind of flexibility, a fourth year in hepatology may not be necessary. On the other hand, if your exposure to liver transplantation is limited during the GI fellowship, you
should seek rotation(s) at hospitals where this experience is offered. The additional training in hepatology is geared toward producing the next generation of academic leaders in this exciting field, which is emerging as a distinct discipline requiring specialized training. In view of this emergence, the American Board of Internal Medicine (ABIM) has approved a Certificate of Added Qualification (CAQ) in Transplant Hepatology (‘‘Board Certification in Transplant Hepatology’’). This certificate is only available to ABIM-certified gastroenterologists; it connotes added qualifications (ie, knowledge of hepatology) beyond what is required for
Key points d
d
d
Understand your personal goals and career ambitions. Confirm that the program has an adequate transplant volume. Verify that the program conforms to current standards.
Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.12.006
board certification in gastroenterology. The first examination will be offered in 2006 and then every other year thereafter. Those who have not completed an additional year at an accredited program will not be eligible to take the examination after 2010. Until then, ABIM-certified gastroenterologists working primarily in transplant hepatology are eligible to sit for the examination without having an additional year of Accreditation Council for Graduate Medical Education (ACGME)-accredited training (‘‘grandfather clause’’). The first board review course for the CAQ will be offered September 16-17, 2006, in Chicago, Illinois (details available at www.aasld.org). Presently, 37 GI training programs in the United States offer a fourth or additional year of advanced hepatology training. These programs vary significantly in their curricula and infrastructure. However, the advent of the CAQ will require that all programs meet specific criteria to be accredited by the ACGME. This standardization is clearly in the best interest of trainees, as it will improve the overall quality of existing programs. Those programs that cannot meet the criteria
674 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
Bansal
will not be certified. Thus, it is critical for GI fellows now contemplating an additional year to carefully review prospective programs to ensure that they conform to current standards (available at www.aasld.org/eweb/docs/caq. pdf).1-4 By meeting the following requirements, hepatology programs will ensure comprehensive training and eligibility for their trainees who plan to take the CAQ examination in transplant hepatology.
WHAT SHOULD YOU BE LOOKING FOR IN A PROGRAM 1. Adequate transplant volume: at least 30 liver transplants each year or 20 transplants each year for each fellow to be trained. The transplant program must be approved by the United Network for Organ Sharing and be affiliated with an ACGME-approved gastroenterology training program. 2. Exposure to the following: the process of listing patients for liver transplantation; contraindications to transplantation; management options for hepatocellular carcinoma; post-transplant management of acute and chronic processes (including disease recurrence); tailored immunosuppression; living related-donor transplantation; experience in performing US-guided liver biopsy; management of fulminant hepatic failure and acute variceal bleeding; and appropriate use of interventional radiologic procedures. 3. Training in the indications for, performance of (at least 20 biopsies), and pathologic interpretation of liver biopsies (at least 200). 4. Large faculty with various areas of expertise in basic, translational, and clinical hepatology. 5. Strong relations with the surgical faculty, with combined conferences and delivery of integrated care in the pre-, peri-, and post-transplant setting.
www.giejournal.org
Third-tier fellowship training in hepatology
6. Defined curriculum, syllabus, and educational objectives, as well as lecture series covering all relevant topics in transplant hepatology. 7. Defined mentorship for career development. 8. Fellowship program training in living donor transplantation: if such training is not available on-site, the institution must provide travel and accommodations to gain this experience. The fellow must evaluate at least 5 potential donors and understand the contraindications to donation, ranging from psychosocial factors to medical factors like excessive liver steatosis. While the decision to obtain training is not always easy, transplant hepatology offers GI fellows the opportunity to develop into leaders in a dynamic, exciting, and increasingly lucrative sub-discipline within gastroenterology. Until uniform standards for programs are instituted, however, careful scrutiny is advised to ensure that prospective programs adhere to emerging standards so as to optimize opportunities for future success. Meena B. Bansal, MD Assistant Professor of Medicine Advanced Hepatology Fellowship Director Mount Sinai School of Medicine New York, New York, USA
REFERENCES 1. Bacon B. Certificate of added qualification in transplant hepatology. Liver Transpl 2005;11:4-6. 2. Cohen S, Gundlapalli S, Shah R, et al. The downstream financial effect of hepatology. Hepatology 2005;5:968-75. 3. Fried MW. Certificate of added qualification for hepatology: vindication not vanity [editorial]. Gastroenterology 2005;128:817. 4. Rosen HR, Fontana RJ, Brown RS, et al. Curricular guidelines for training in transplant hepatology. Liver Transpl 2002;8:85-7.
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 675
Third-tier fellowship training in hepatology: advantages and program selection As the practice of hepatology becomes increasingly complex, many fellows are opting for additional training. This month our guest author, Dr. Meena Bansal, discusses the benefits of obtaining advanced training in hepatology, as well as issues to consider when choosing a program. Kevin J. Peifer, MD Fellows’ Corner Associate Editor Fellow Division of Gastroenterology Washington University St. Louis, Missouri, USA By the time GI fellows reach the end of their fellowship, the prospect of yet another year of training – which typically follows 6 years of residency and fellowship – can be daunting. The decision to take on this additional year is a personal one and can best be focused around the question: ‘‘Where am I now, and where do I want to go with my career?’’ In truth, given the opportunities to customize training within a GI fellowship, this question might be best raised at the outset of the fellowship. Quite simply, if a GI trainee expects to practice transplant hepatology in an academic center or to serve as the ‘‘resident hepatologist’’ as part of a larger community-based gastroenterology group, the answer is clear: an additional year of transplant hepatology is strongly advised. However, the answer is less clear if you simply wish to be comfortable managing patients with acute and chronic liver disease, as well as end-stage liver disease before transplantation. In this case, your decision depends on the quality of your GI fellowship – in particular, how much exposure you had to managing patients with liver disease. For example, GI fellows at Mount Sinai rotate on the liver transplant service for 3 months during their second fellowship year and participate in the liver continuity clinic throughout the fellowship. If, however, a fellow expresses a specific interest in liver disease, he or she may spend additional time on the liver service during the third year. If your program offers this kind of flexibility, a fourth year in hepatology may not be necessary. On the other hand, if your exposure to liver transplantation is limited during the GI fellowship, you
should seek rotation(s) at hospitals where this experience is offered. The additional training in hepatology is geared toward producing the next generation of academic leaders in this exciting field, which is emerging as a distinct discipline requiring specialized training. In view of this emergence, the American Board of Internal Medicine (ABIM) has approved a Certificate of Added Qualification (CAQ) in Transplant Hepatology (‘‘Board Certification in Transplant Hepatology’’). This certificate is only available to ABIM-certified gastroenterologists; it connotes added qualifications (ie, knowledge of hepatology) beyond what is required for
Key points d
d
d
Understand your personal goals and career ambitions. Confirm that the program has an adequate transplant volume. Verify that the program conforms to current standards.
Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.12.006
board certification in gastroenterology. The first examination will be offered in 2006 and then every other year thereafter. Those who have not completed an additional year at an accredited program will not be eligible to take the examination after 2010. Until then, ABIM-certified gastroenterologists working primarily in transplant hepatology are eligible to sit for the examination without having an additional year of Accreditation Council for Graduate Medical Education (ACGME)-accredited training (‘‘grandfather clause’’). The first board review course for the CAQ will be offered September 16-17, 2006, in Chicago, Illinois (details available at www.aasld.org). Presently, 37 GI training programs in the United States offer a fourth or additional year of advanced hepatology training. These programs vary significantly in their curricula and infrastructure. However, the advent of the CAQ will require that all programs meet specific criteria to be accredited by the ACGME. This standardization is clearly in the best interest of trainees, as it will improve the overall quality of existing programs. Those programs that cannot meet the criteria
674 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
www.giejournal.org
Bansal
will not be certified. Thus, it is critical for GI fellows now contemplating an additional year to carefully review prospective programs to ensure that they conform to current standards (available at www.aasld.org/eweb/docs/caq. pdf).1-4 By meeting the following requirements, hepatology programs will ensure comprehensive training and eligibility for their trainees who plan to take the CAQ examination in transplant hepatology.
WHAT SHOULD YOU BE LOOKING FOR IN A PROGRAM 1. Adequate transplant volume: at least 30 liver transplants each year or 20 transplants each year for each fellow to be trained. The transplant program must be approved by the United Network for Organ Sharing and be affiliated with an ACGME-approved gastroenterology training program. 2. Exposure to the following: the process of listing patients for liver transplantation; contraindications to transplantation; management options for hepatocellular carcinoma; post-transplant management of acute and chronic processes (including disease recurrence); tailored immunosuppression; living related-donor transplantation; experience in performing US-guided liver biopsy; management of fulminant hepatic failure and acute variceal bleeding; and appropriate use of interventional radiologic procedures. 3. Training in the indications for, performance of (at least 20 biopsies), and pathologic interpretation of liver biopsies (at least 200). 4. Large faculty with various areas of expertise in basic, translational, and clinical hepatology. 5. Strong relations with the surgical faculty, with combined conferences and delivery of integrated care in the pre-, peri-, and post-transplant setting.
www.giejournal.org
Third-tier fellowship training in hepatology
6. Defined curriculum, syllabus, and educational objectives, as well as lecture series covering all relevant topics in transplant hepatology. 7. Defined mentorship for career development. 8. Fellowship program training in living donor transplantation: if such training is not available on-site, the institution must provide travel and accommodations to gain this experience. The fellow must evaluate at least 5 potential donors and understand the contraindications to donation, ranging from psychosocial factors to medical factors like excessive liver steatosis. While the decision to obtain training is not always easy, transplant hepatology offers GI fellows the opportunity to develop into leaders in a dynamic, exciting, and increasingly lucrative sub-discipline within gastroenterology. Until uniform standards for programs are instituted, however, careful scrutiny is advised to ensure that prospective programs adhere to emerging standards so as to optimize opportunities for future success. Meena B. Bansal, MD Assistant Professor of Medicine Advanced Hepatology Fellowship Director Mount Sinai School of Medicine New York, New York, USA
REFERENCES 1. Bacon B. Certificate of added qualification in transplant hepatology. Liver Transpl 2005;11:4-6. 2. Cohen S, Gundlapalli S, Shah R, et al. The downstream financial effect of hepatology. Hepatology 2005;5:968-75. 3. Fried MW. Certificate of added qualification for hepatology: vindication not vanity [editorial]. Gastroenterology 2005;128:817. 4. Rosen HR, Fontana RJ, Brown RS, et al. Curricular guidelines for training in transplant hepatology. Liver Transpl 2002;8:85-7.
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 675