By Scott L. Friedman, MD
It has become increasingly clear that we face the threat of diminishing availability of hepatologists at just the time when an explosive growth in new therapies offers unprecedented hope to patients with acute and chronic liver diseases. A survey of 22 hepatology training directors by Andrew Keaveny, MD in December 2008 (summarized in this newsletter) revealed some distressing facts: 20 of 22 directors thought changes were required to the current training structure, and almost half of their programs currently had no fellows. Even with this shortfall in trainees, most felt that hepatology training should not be separated completely from gastroenterology. Thus, despite the success in defining transplant hepatology as a discrete discipline meriting an examination with certification, this career path has not appealed to enough young physicians.
There are many potential explanations for these findings, but to me the most compelling are: 1) an extra year of training after GI fellowship is simply one obstacle too many, as it often requires relocation to a separate city at a time when many trainees have mounting debt, young families, and fatigue from lengthy training; 2) interest in a hepatology career at the outset of a GI fellow’s training might wane by the time it is necessary to apply for an Advanced Hepatology Fellowship; and 3) caring for patients with liver disease is perceived as difficult work that is not adequately reimbursed.
The experience in my institution among our medicine residents suggests that hepatology is considered an exciting and intellectually challenging career, but the duration of training is indeed a turn-off. On the positive side, hepatologists’ salaries have risen dramatically, albeit due to the growing shortage in the field (most transplant hepatology programs have openings for additional faculty), and furthermore, the work can be extremely gratifying in view of new treatment options for liver disease, as well as the success of transplantation.
With this impending manpower shortage, past and present AASLD leadership has vigorously advocated for a review of the training pathway in hepatology (1-3). In response to this concern, a Four-Society GI Training Task Force was convened this past spring, with two representatives each from AGA, ACG, ASGE, and AASLD, and chaired by Dr. Lawrence S. Friedman (no relation) of Newton-Wellesley Hospital, and former Chair of the American Board of Internal Medicine Gastroenterology Specialty Board. AASLD has been represented by former President Gregory Gores, MD of Mayo Clinic, and 2012 AASLD President, J. Gregory Fitz, MD of UT Southwestern.
The Task Force worked with remarkable collegiality and efficiency, and created a document that has already met with the approval of all four societies. The final document has been published simultaneously in each of our journals this month (4). The Task Force proposed a training template in which GI Fellows can identify hepatology as a specialized interest within their GI fellowship, thereby obtaining their advanced hepatology training within the three-year time frame. This sub-discipline structure could additionally appeal to those seeking similar specialized training in inflammatory bowel disease, GI oncology, advanced endoscopy, or other areas of specialized expertise. All GI Fellows would take the same general GI fellowship exam after three years, and those pursuing hepatology or the other disease areas could take an additional certification exam within one to two years after completing GI training. This plan would be similar to the current certification for sub-specialists in Hospital Medicine, who take a sub-specialty certification exam following two years in clinical practice after medicine residency.
Although a number of issues need to be ironed out, particularly with certifying bodies such as the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education, this proposal surmounts at least two of the three key obstacles I outlined above, and it provides a straighter path to expertise in hepatology. Moreover, the third obstacle (inadequate remuneration) has been largely overcome by market forces that put a premium on transplant hepatology skills to support successful liver transplantation programs.
It is unclear what impact the current deliberations about health care reform will have on the appeal of this path, but currently all signs point to increased appreciation of cognitive specialties – and few disciplines are more cognitive than hepatology! This increased recognition of cognitive specialties, combined with the growing excitement about new treatments for liver disease, could greatly enhance the future for our specialty. AASLD leadership is firmly dedicated to the goal of shortening the path to a career in hepatology, and will work closely with its counterparts in AGA, ACG, and ASGE to make it a reality.
As this is my final eNews column as AASLD President, I want to express my sincere gratitude to the association, its staff, leadership, and membership for allowing me the opportunity to convey my views through this newsletter. Presiding over last month’s incredibly successful annual meeting was the highlight of my professional life. It has been a joy and a privilege for me to lead this marvelous organization, and I wish my successor Arun Sanyal great success.
References
1. Rustgi VK, Davis GL, Herrine SK, McCullough AJ, Friedman SL, Gores GJ. Future trends in hepatology: challenges and opportunities. Hepatology 2008;48:655-661.
2. Friedman SL, McCullough A, Gores G. Commentary: Gastroenterology and hepatology: an evolving marriage, not an imminent divorce. Am J Gastroenterol 2009;104:10-11; discussion 11-12.
3. Bacon BR. Hepatology: small steps forward. Gastroenterology 2008;134:381.
4. Friedman LS, Brandt LJ, Elta GH, Fitz JG, Gores GJ, Katz PO, Kuemmerle JF, et al. Report of the multisociety task force on GI training. Hepatology 2009; 50:1325-1329.
This electronic newsletter is a bi-weekly publication of AASLD and replaces the former bi-monthly print newsletter and weekly e-news. Members are welcome to submit articles and may send suggestions to aharan@aasld.org.