Training in Hepatology: Where Are We Now?

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Over the past 3 years, I have had the pleasure of serving as an Associate Editor for Gastroenterology, especially in the context of clinical hepatology. This has been an enriching and educational experience and I hope the readership of the Journal and their patients have benefited from the exciting work that has been published. As a separate consideration, I have been interested in training and certification in gastroenterology as Chair of the American Board of Internal Medicine (ABIM) Gastroenterology Board from 1999 to 2003, and as the current Chair of the ABIM Transplant Hepatology Board since 2004. I have elected to write periodically about the evolution of hepatology as a distinct entity, which has taken place over the last 5–10 years. Currently, this evolution has culminated in a certifying examination given by the ABIM so that board-certified gastroenterologists who have special expertise in advanced/transplant hepatology (TH) can become board certified in TH. Two certifying examinations in TH were administered in November of 2006 and 2008 and 88% of both adult and pediatric gastroenterologists passed the examination. As a result, there are now nearly 380 board-certified transplant hepatologists (adult and pediatric combined). After the development of a certifying examination, the Accreditation Council for Graduate Medical Education (ACGME) developed criteria for accreditation of training programs. According to the ACGME, as of academic year 2007–2008, there were 21 TH programs accredited with a total of 36 slots allotted for training. Unfortunately, the ACGME has required that TH training be done after training in gastroenterology. It is my perspective that this requirement has negatively impacted the number of interested physicians willing to pursue this additional year of training. Another problem that has become apparent is that the ABIM, in its original development of the TH examination, required that all candidates be board certified in gastroenterology. These 2 requirements from the ACGME and from the ABIM have created a problem that was unforeseen as the discipline evolved while the certifying examination and the accreditation of programs were developed.

Because gastroenterology has been a popular subspecialty amongst graduates of Internal Medicine (IM) residencies, there have been many more applicants than positions for at least the last 10 years. Thus, there have been more qualified IM graduates than positions in gastroenterology; this has been coupled with a need for physicians trained in hepatology. As a result, training programs developed in hepatology/TH quickly filled up, leading to IM graduates being trained in TH. Many of these individuals never went on to get further training in gastroenterology. With the proliferation of hepatology as a distinct discipline and the shortage of individuals trained in caring for these complex patients, salaries have been competitive and physicians are now trained in hepatology and are practicing as hepatologists at transplant centers without expertise in gastroenterology. The exact number of individuals in this pathway is unknown, however.

The problem that has been created by the rules from the ABIM and the ACGME and the lack of interest in developing hepatology as a truly independent discipline have resulted in a large number of individuals practicing hepatology who are neither certified nor certifiable and who have not been trained at an ACGME-accredited program. Although there has been a push for hepatology training to occur directly after IM, that approach has been stymied. Instead, a multisociety (American Gastroenterological Association [AGA], American Association for the Study of Liver Diseases [AASLD], American College of Gastroenterology [ACG], and American Society for Gastrointestinal Endoscopy [ASGE]) task force on gastroenterology training, chaired by Dr Lawrence Friedman, was commissioned to determine what changes, if any, should be made in gastroenterology training and certification to accommodate the need for subspecialists within the field. This task force has met and published the results of its deliberations (Gastroenterology 2009;137:1839–1843). Relative to TH, the task force has suggested that overall training be reduced to 3 years (18 months of gastroenterology and 18 months of advanced hepatology/TH). Candidates could take an examination for certification in gastroenterology after 3 years, but would have to wait another 2 years and participate in a “maintenance of certification” (MOC) program before being eligible for certification in TH. The reason for this recommendation by the task force seems unfounded. An alternative suggestion for dealing with the disciplines of gastroenterology and hepatology would be to do what we do for hematology and oncology or pulmonary medicine and critical care. Candidates could be trained for 3 years (divided between gastroenterology and advanced/TH) and take board certification examinations in both gastroenterology and TH without the extra 2 years of MOC. Other components of the task force recommendations are for internists to enter into gastroenterology training and have the opportunity to “spin off” into other sub-subspecialty disciplines such as gastrointestinal cancers, motility, inflammatory bowel disease, interventional endoscopy, or to continue in general gastroenterology. It is not clear how “certification” would occur in these other gastroenterology sub-subspecialties.

As a discipline, the time for evaluating gastroenterology subspecialization is now upon us and we welcome the opinion of the task force, recognizing that different curricula models apply to these different pathways, not just hepatology/TH. The task force has suggested that all of these specific avenues of training could be completed within 3 years, thus obviating the need for a 4th year as we now have in TH. The concern about individuals not wanting to do 4 years of training is evident by the fact that there are currently 36 ACGME-accredited TH slots available, and only 14 positions filled (personal communication, A. Keaveny). Although the work of the task force will indeed be valuable and worthwhile, the recommendation for those in TH to require 2 additional years of MOC is unnecessary.

Whether or not this plan to revise gastroenterology training will gain traction is unknown, but a readily perceived problem with this approach is that it is unlikely that the ABIM will be willing or able to put the resources into multiple sub-subspecialty test writing and examination committees. Alternatively, it would be rational to continue gastroenterology training as it is and to develop training programs for hepatology. This training could certainly follow an initial 1–1.5 years of gastroenterology as recommended by the task force. Candidates should be eligible for certification in both gastroenterology and TH at the completion of training. Finally, some attention should be directed toward providing an avenue for certification for those individuals who have already trained in hepatology.

It is important for the leadership of the gastroenterology subspecialty societies (AGA, AASLD, ACG, and ASGE), the ABIM and the ACGME to come together with a training solution that truly meets the needs of hepatology and our patients with liver disease. Presumably, the next step in this process will be to present recommendations to the Gastroenterology Board of the ABIM for further deliberation and refinement. Hopefully, we can make some progress and move forward.