Okay, thank you Helen. So these are the questions that came from a question bank developed by current and former members of the MOC committee. Many of us attended a one-day training session on developing these questions. And I'll say that if you've never written a question, it's a lot harder than you might think. That said, we think that there's value for those of us who may be preparing for exams or trying to stay up to date to have practice materials available. We were discussing in our committee meeting yesterday that there's a wealth of questions out there in gastroenterology. Lots of practice to be had in various sources. Not so much within transplant hepatology. And we think that that might be something valuable for us to have available to us for ourselves, for our trainees we work with. And the questions that we're going to go through today are already available to you on liver learning and you can earn two and a half, yes, two and a half MOC credits by answering those online. I have no disclosures. So we'll move on to the first question here. Which of these patients presenting with acute liver failure has the best prognosis for transplant-free survival? Hepatitis B virus infection, ischemic hepatitis, Wilson's disease, and aminatofluoides toxicity. Oh, yeah, we don't have a question response system set up. We can do. Could do. All right. Show of hands for A, B, C, and D. Okay. Most of you are correct here. So correct answer is B, ischemic hepatitis, or often called shock liver. This is seen in the setting of cardiac arrest, any period of significant hypovolemia or hypotension, or in individuals with severe congestive heart failure. And stabilization of the cardiac dysfunction or circulatory dysfunction really determines outcome for these patients. Transplantation is seldom required. I think outcomes from a liver standpoint are good, although really long-term outcomes are not great for these patients because of underlying cardiovascular disease. So that's why the answer was correct. In terms of the other options there, nucleoside or tied analogs should be considered for acute liver failure due to hepatitis B, whether it's acute infection or reactivation. But transplant-free survival is poor in these patients, and there's no consensus about the true efficacy of therapy in this setting. Fulminant presentation of Wilson's is considered universally fatal without liver transplantation. And mushroom poisoning, ALF, is also associated with low transplant-free survival. Silibinin is not FDA-approved, but can be efficacious. Penicillin G and NAC may improve outcomes, but overall these are patients who need transplant. Okay. Second question, 37-year-old woman, G2P1, presenting at 32 weeks of gestation with three weeks of intense diffuse itching. Her itching is keeping her awake at night. She's got diffuse excoriations. On examination, she has scleral icterus. She's alert and oriented and has no asterixis present. She has an ultrasound with normal liver, spleen, and vasculature. Her acute viral serologies are all negative, and selected labs are shown here. So you can see a relatively normal hemoglobin, normal platelet count, and blood sugar. Keratinine and urinalysis are normal. ALT and AST markedly elevated. Silirubin 4, INR normal, and bile acid level 32. So which of the following is the next best step in her management? A, deliver the baby early at 34 weeks. B, test for L-CHAD. C, perform a liver biopsy. D, start ursodeoxycholic acid. Or E, transfuse platelets with delivery. So show of hands for A. All right, great. So you all, I think, recognize this was a case of intrahepatic cholestasis of pregnancy. This typically presents in second or third trimester with severe itching, elevated bile acids. Up to a quarter of these cases may have jaundice, and transaminases can be elevated to greater than 1,000. ERSO may help improve symptoms, improve laboratory parameters, and potentially have positive impact on fetal outcomes. Early delivery is recommended for intrahepatic cholestasis of pregnancy, but the recommended delivery time is 37 weeks. Testing for L-CHAD deficiency, this is typically done in cases of acute fatty liver pregnancy. This condition, intrahepatic cholestasis of pregnancy, is really a clinical diagnosis with the features listed here. So in a case where features are meeting these basic criteria, there's not really a role for performing liver biopsy for diagnosis. And finally, platelet transfusion with delivery is something that you might consider in the setting of HELP syndrome rather than this particular complication of pregnancy. Okay. Third question. A 42-year-old man who underwent liver transplant for alcohol-induced liver disease is maintained on immunosuppression with tacrolimus and mycophenolic acid. Routine laboratory studies are checked three months after transplant with the following results shown. So you see some elevation present in ALT-AST, bilirubin, alkaline phosphatase, GGT, and a tacrolimus trough level of 6.7. Liver biopsy is performed with representative images shown here. The question is, what is the next best step in this patient's management? A, hepatic artery angiogram, B, endoscopic retrograde cholangiopancreatography or ERCP, C, valgan cyclophere, D, methylprednisolone, or E, alcohol abstinence and counseling. Show of hands for A, B, C, D, E. All right. So you all recognize the histological features of acute cellular or T-cell mediated rejection listed here. This can occur in 10 to 30 percent of transplant recipients, even those who are following their recommended immunosuppressive regimen. Treatment of mild to moderate rejection typically involves increased background immunosuppression and corticosteroids. The other answers really were incorrect on the basis of the biopsy finding, what was there and what was not there. So we wouldn't expect hepatic artery stenosis to cause venulitis. There was no evidence of biliary obstruction or ascending cholangitis on the histology. Likewise, no features of CMV infection or of alcoholic hepatitis. Next question, 58-year-old man, obesity, diabetes, and hypertension is admitted with three weeks of jaundice, abdominal bloating, and malaise. He usually drinks three to four beers a day after work and 12 to 18 beers on weekends, but admits to increased consumption over the last nine months after losing his job. His last alcohol use at the time of admission was two weeks ago, and he presents with a temperature of 99, blood pressure 98 over 62, heart rate 96, respiratory rate 20, and oxygen saturation 94 percent on room air. Examination is notable for jaundice, lower extremity edema, a distended abdomen, and asterixis. He has an elevated white blood cell count, creatinine of 1.5. His MELD score is 29 and discriminant function 41. So which of the following is the most appropriate initial treatment for this patient? A, initiate therapy with glucocorticoids. B, order a low-sodium diet and intravenous diuretics. C, complete an infectious evaluation, initiate lactulose, and screen for nutritional deficiencies. D, initiate parenteral nutrition support, or E, administer oxazepam for management of alcohol withdrawal. So who would choose A? Okay, so the description of this case really met clinical criteria for diagnosis of acute alcoholic hepatitis, summarized here from the recently published guidelines in Hepatology this year. And alcohol abstinence, nutrition support, folic acid, B vitamin, and zinc supplementation, and avoidance of nephrotoxins are really felt to be the mainstays of best supportive care in this particular case. The features of systemic inflammatory response syndrome or SIRS, this is a particularly ill patient in whom at least some initial investigation for active infection may be warranted before initiating steroids, although that's not technically an incorrect therapeutic in a case like this. Stores for prognostication are endorsed by the guidelines. With his SIRS and creatinine on admission of 1.5, initiating diuretics does carry some risk for precipitating worsening renal function. Oral or enteral nutrition support are favored whenever possible rather than parenteral nutrition. And in this case, having quit drinking two weeks ago and some asterixis on admission, probably monitoring for withdrawal rather than administering benzodiazepines out of the gate would be appropriate. Okay, 50-year-old woman presents to clinic for evaluation of abnormal liver enzymes. She has a medical history significant for rheumatoid arthritis, hyperlipidemia, and breast ductal carcinoma in situ. Her current medications are Etanercept, Simvastatin, and Tamoxifen. She recently completed a three-day course of nitrofurantoin for a urinary tract infection. She does not drink alcohol. Labs are shown below, and of note, her alkaline phosphatase and total bilirubin were normal. So you can see here elevation of her ALT and AST. She does have positive autoantibodies, and ferritin only minimally elevated with a normal iron saturation. So liver biopsy is shown here. Which of the following medications is most likely to cause this pattern of liver injury? A, Simvastatin, B, Tamoxifen, C, Etanercept, or D, nitrofurantoin? Show of hands for A, B, C, or D. Okay. So drug-induced liver injury or DILI due to Tamoxifen manifests as a fatty liver type injury. Typically, this occurs after one to two years of therapy, and in some cases, can be progressive. As most of you, or if not all of you, are aware, Simvastatin can produce an elevation of the liver enzymes, ALT, AST. This is usually mild and usually transient. Etanercept has been associated with autoimmune-type liver injury and induction of autoantibodies. So while she did have autoantibodies, the histology really is key to identifying the most likely cause of liver injury in this case. Nitrofurantoin is one of the most common causes or best-recognized causes of DILI. Acute injury is typically hepatocellular in pattern, and chronic injury in patients who are on long-term prophylaxis can mimic autoimmune hepatitis. Okay. Next case, 62-year-old man presents with progressive dyspnea and nonproductive cough. He underwent liver transplant 18 months ago for hep C cirrhosis with HCC. His course has been complicated by an episode of acute cellular rejection, followed by CMV colitis. His blood and sputum cultures were negative. CT thorax is shown. You can see a pulmonary nodule, and bronchoalveolar lavage is positive for cryptococcus. So which of the following is the most appropriate initial management of this invasive fungal infection? A, CT-guided biopsy of the long nodule to exclude malignancy. B, withdrawal of mycophenolate and decrease in calcineurin inhibitor by 50%. C, surgical consultation for resection of pulmonary cryptococcoma. D, lumbar puncture with measurement of opening pressure. And E, resume CMV prophylaxis with falguncyclovir. Let's show of hands for A, B, C, D, E. All right, well, either people are totally over it or stumped. Okay. All right, correct answer is D. Crypto can present in a number of ways with pneumonia, isolated meningitis, or disseminated disease. It's advised that all transplant recipients on long-term immunosuppression identified with cryptococcal infection should undergo lumbar puncture or suspected cryptococcal infection should have lumbar puncture. Mortality with CNS involvement in crypto is quite high. So that's the initial recommendation in this particular case. Biopsy of the pulmonary nodule is not technically wrong to rule out malignancy in somebody who was transplanted for HCC, but that wouldn't be your initial move in this case. Rapid reduction of immunosuppression with initiation of antifungal therapy in some cases can lead to this immune reconstitution inflammatory syndrome, which can mimic worsening underlying cryptococcal disease. So while reducing immunosuppression and starting antifungal therapy is appropriate for management, just to be aware of this can occur if we're in certain cases where we are doing brisk reduction in immunosuppression. Surgical resection is almost never utilized for this indication, and there's no indication in this case for resumption of CMV prophylaxis. Okay. The 49-year-old woman undergoes liver transplant for alcoholic cirrhosis. The donor biopsy at the time of procurement had a 30% microvesicular steatosis. On post-op day three, the recipient remains intubated in the surgical intensive care unit, hypothermic, and requiring vasopressor support. Ultrasound of the liver with Doppler reveals slightly increased resistive indices in the hepatic artery with a patent portal vein. ALT and AST are both over 2,000. Total bilirubin is 14, and INR is 3.7. What's the next best step in management of this patient? A, high-dose methylprednisolone, B, hepatic artery angiography, C, ERCP, or D, relist for liver transplant. Show of hands for A, B, C, D. Okay, correct. So this is a case of primary nonfunction defined as poor initial allograft function, and these are patients who have very high risk of mortality without retransplantation and so should be relisted and are given UNOS criteria as status 1A. Clinical instability and liver dysfunction really are more typical or suggestive of PNF than a hyperacute rejection, which is rare. Hepatic arterial stenosis or thrombosis is not supported by the ultrasound results that were reported in this case, and biliary complications are most often a little later and usually not manifest by features of liver failure. Okay, 34-year-old woman undergoes a stem cell transplant for acute myeloid leukemia. She receives myeloablative conditioning therapy with busulfan and cyclophosphamide. On day 15 after transplant, she develops jaundice, right upper quadrant pain, and ascites. She undergoes a transjugular liver biopsy. There's a normal venogram. The HVPG is 18, and the histology shows congestion in zone 3 with associated hemorrhage, college deposition within the central veins. What is the best treatment for this patient? A, intravenous heparin, B, thrombolysis, C, defibrotide, D, TIPS, or E, liver transplantation. Show of hands for A, B, C. So, this is sinusoidal obstruction syndrome, or SOS, and defining criteria, Seattle criteria, are shown here. Defibritide has fibrinolytic, antithrombotic, and anti-ischemic properties, and is currently the only FDA-approved therapy for treatment of severe SOS. There have been studies of both heparin and TPA. Studies have been associated with low response rates and high rates of bleeding complications. A TIPS in a case like this certainly could improve ascites and kidney function, but is not associated with improved survival, and transplant is very rarely performed in cases of SOS. Okay, 15-year-old white male presents to your clinic with elevated liver enzymes. He does not smoke. He does not drink alcohol. He has no family history of liver disease or liver cancer. Right upper quadrant ultrasound is normal, and laboratory, selected laboratory results are shown. Platelet count is normal. ALT and AST mildly elevated. Alkaline phosphatase and albumin normal. Hepatitis B and C markers of chronic infection are negative. Sperm saturation 45%, ferritin 1,200, and he had two copies of the C282Y gene on HFE testing. Oh, well. You're welcome. No. Sorry about that. Okay, so choices, either you're done testing, phlebotomy, liver biopsy, take a family history, or repeat the IRNN panel in three months. Okay, so current practice guidelines, so the last ASLD guidelines, I think, are from about 10 years ago or close to 10 years ago. There was a publication in the Red Journal of some ACG guidelines on hemochromatosis this year, but both advocate for liver biopsy in C282Y homozygotes who have a serum ferritin greater than 1,000 for purposes of staging fibrosis, and I just showed here the recent ACG guidelines explicitly state that they're not recommending elastography for fibrosis staging in this setting. A phlebotomy is recommended as first-line treatment in patients diagnosed with hereditary hemochromatosis, and so that is appropriate therapy, but the first step in a case like this is to perform staging liver biopsy. Family members, particularly first-degree relatives of these patients, should be screened for hereditary hemochromatosis, and clearly no further workup or follow-up IRNN studies in three months are both incorrect because this patient has mildly elevated enzymes and a ferritin over 1,000. Okay, last one. The risk of which of the following is reduced by the use of rituximab prophylaxis for ABO-incompatible liver transplantation? A, acute cellular rejection, B, antibody-mediated rejection, C, bacterial infection, D, fungal infection, or E, cytomegalovirus disease? Oh, man. I guess I anticipated you guys were going to be like done on answering by the end. I apologize for that. Okay, so the correct answer is everybody's favorite. This was a hot topic, I think, on one of the recent transplant hepatology examinations, ABO-incompatible. Okay, so antibody-mediated rejection is associated with decreased survival after transplant, and the bulk of the data for this derived from a multicenter study of Japanese patients who underwent ABO-incompatible live donor liver transplant and found that rituximab as prophylaxis reduced the risk for developing antibody-mediated rejection. So serious infections, be it bacterial, fungal, or viral, have been associated with rituximab therapy. This therapy, when used to reduce risk for antibody-mediated rejection in this clinical scenario, was not associated with reduced risk for infectious complications. And rituximab, which depletes B cells, is not utilized in therapy of acute T cell-mediated rejection. Okay, so well done. Hopefully that was useful, or having questions like that would be useful. It does take some effort to develop these, but I think it's helpful when we are preparing for examinations or trying to provide teaching materials to our trainees to have questions like that available for our use. So that brings us to the end of our presentations and gives us some extra time for our question and answer. So let's bring all of our speakers back up. Thank you. And so we'd like to open this up for questions from the audience for any or all of our panel members. My name is David Dees. I'm a transplant hepatologist. I was the honor of the first ASL member to join the MBPAS. It was painless. It was the smartest thing I ever did. I've had zero problems in a courtroom with insurers, hospital. I would recommend it to everybody. Where do you practice? In Louisiana. My question is, we were shown data on the generous salaries of the ABIM. Can you comment on the salary of the Board of Directors for the MBPAS? So the Board of Directors for the MBPAS are all volunteers, so none of us receive salary. Some of us that do speaking do get some travel expenses covered and occasional honoraria, but, yeah, none of us are salaried. My final question is, how many members does the MBPAS have now, sir? Right now, our executive director, Katie Collins, is in the back of the room, but I'm told about 7,000. 8,000. 8,000. Sorry. Couldn't see the thumb. Thank you. Yeah. Why are there so many CME courses that don't offer MOC? Brian, do you want to answer that? Yeah. I'll let Katie officially say, but I think, ultimately, it needs to go through a pretty stringent vetting process, and so not all of them qualify for it. I think I heard some discussion about the ASGE endoscopy course, and I'll let Katie weigh in on that officially. Yeah. We're trying to add more and more each year, and it may come very soon that we are able to offer it for the full meeting, so we're working on ways that we can do that, so we have to offer it in a variety of ways, and we've been working with the ABIM specifically for MOC that we might be able to offer it just for the full meeting next year, so it's in process. We've added on each year since 2015. There were, I think, three sessions offered that year, and every year, we've incrementally added more, but we'd like to just go ahead and offer it for the full meeting, so more to come on that. We're working on it. I'll also say that if you're involved in a fellowship training program, your program director gets an email once a year, and they can, because most faculty are involved in quality improvement projects, we automatically enroll all of our faculty, and everybody gets 20 points every year by doing that mechanism, so people don't even know they're getting those points, but your program director, at least if you're in an academic training program with a fellowship, you'll get that request, and so that's another easy way to get points without really doing anything beyond what you're already doing, so I don't do, I don't know, are there program directors here that do that for all their faculty, do you all know about that? I mean, at least as a program director, I get the email, so it's an easy thing to do. I tried to see whether my GI program director would be able to put my name in so I could get twice, but it doesn't work that way, and so when I put my faculty in for transplant pathology because we are a combined division, he can't put in my name again for points for him, so the GI people get the 20 points from GI, and that transplant pathology faculty get the 20 points for what I do. So that would be 10 points? 20 points, period. 20 points, but you can't double dip for GI and transplant pathology. You can't double dip, so I can't, because I'm both the GI and transplant pathology faculty, I don't get 40 points. I only get 20. I tried, and... 20's not bad. Yeah, 20's not bad, exactly. I don't think we've ever gotten that, have we? Well, I think it's up to your program director. He's the one that has to do that, so you need to let them. He could ignore the email. I don't ignore emails, or at least I don't ignore most of my emails, and so you just need to talk to your GI program director for you. Helen? I have a question. So as a consumer, I always welcome competition, because things can just only get better, you know, whether with the existing one or the new one. I think for us, it's just going to get better. So my question is to Dr. Matthew. How have you been able to work on having hospitals and payers recognize MBPS to be acceptable for physicians to remain credentialed? Sure. So the vast majority of hospitals and medical systems, as I've mentioned, do require their physicians to participate in MOC because the payers oftentimes encourage them to do so. In areas like South Dakota, where there's a physician shortage, a lot of the time that requirement is not there. So many of the medical staffs don't require MOC because the payers are just happy to have physicians practicing there. Currently, there's about 170 hospitals which have independently made the decision that they are not going to require MOC with the practicing physicians there. And again, we think it's important from a public perspective that physicians do remain certified. But we also believe that it's important that physicians have a choice whether they want to continue their certification with the National Board of Physicians and Surgeons or through MOC compliance. And, you know, at the end of the day, we also believe in continuing education. We think it's extremely important. But again, there's so much learning that we do that is not recorded in an online module or in a spreadsheet. Every time we see a patient, I don't care if you've been in practice for 10 years, 15 years, there are little nuances that you will pick up and that will reinforce your knowledge when you discuss cases with colleagues. And in this day and age, when you're not sure about something, what do you do? You pull out your cell phone. You look at up-to-date. You look at some other resource. And that kind of live learning that happens constantly is just not measured in spreadsheets and is not recorded. And really, to afford physicians the ability to select the CMU that best suits their weaknesses and their interests is tremendously important. Like I said, I'm a headache specialist. So to be required to relearn multiple sclerosis and stroke and things like that when I see 100% headache medicine does not make particular sense. I would probably argue the same. Most of the people in this room practice just liver disease and hepatology, maybe some GI. But then why are you being required to learn? And I think that's a good move that the ABMS made, that if you are a specialist, you don't necessarily have to recertify on your primary board in addition to continuing your specialty certification. So I think the ABMS is making some good moves. I personally testified at the Visions Commission. So there's a lot of very healthy discussion. I think the generation of NBPS has helped foster some of that discussion. So I think that's really important. Dr. Reddy? Jonathan Reddy, Chicago. So is the NBPS aware that the ACGME have now in their new common program requirements required that the key clinical faculty in any training program be boarded by an ABMS certified board? Right. So some of the newer legislation that we've been pushing. Historically, a lot of the legislation has been anti-MOC, which we've taken a big step away from. We think MOC, if physicians so want to certify with MOC, they should be allowed to. So we don't believe that MOC is a bad thing necessarily. But again, we believe in physician choice. And some of the newer legislation that we're encouraging is that hospitals and medical systems can require recertification, but they can't require it be from a particular board. And the language that we've actually come to use is it can be from the ABMS, the NBPS, and then any other board that independent hospital wishes to recognize. So that's a very important caveat for two reasons. Let's say you have the world's expert in cardiothoracic surgery and they want to practice at your hospital. The hospital may say, well, this cardiothoracic surgeon is board certified in a board from Ireland. So we are going to make the independent decision to accept that board at our own risk and our own liability in order for this cardiothoracic surgeon who's the world's expert to practice at our hospital. So it gives hospitals a little bit of flexibility in that way. It also protects the public. So believe it or not, there are some crash courses that a general practitioner may take. It's a weekend crash course. And then this crash course will claim, hey, now you're board certified in cosmetic surgery because now you can remove moles, which obviously is very dangerous to equate someone's multi-year fellowship or residency with a weekend crash course in claiming that both people can claim that they're board certified. So certainly we do want to protect the public from fly-by-night boards that will suddenly try to appear and take on the same credence that the ABMS and the MBPAS and respectable boards have. So if that, I don't know if that answers your question. Yeah. I don't think I made myself clear. So the new legislation will actually includes that even for training programs. Well, yeah. So it's the ACGME requirement. Right. And is there any effort to open a dialogue with them to change their rules to accommodate alternative board members? Right. So we are in dialogues with the ACCME and the ACGME. I mean, our preference always is for everyone to be on the same page and work things out that way. But like I said, some of the newer crafted state legislation does actually specify that for whether it's malpractice, insurance carriers, medical staff privileges, and even training programs, residencies, and fellowships. They can require board certification, but they can't require which particular board between MBPAS, ABMS, and like I said, if they wanted to recognize an additional board at their own liability. I don't foresee too many hospitals recognizing other boards for that very reason because it would be at their own risk. So regarding the regular ABIM maintenance of certification, so I like that this new offering is more realistic, real-world type questions, but I don't know that having to answer a bunch of questions every single week is necessarily any less stressful than taking an exam every 10 years. Is there any move towards making that 10-year exam more of a realistic experience rather than a trivia quiz where every 10 years you have to go back and relearn all the things that are completely irrelevant to practicing medicine? I think part of the dialogue has been exactly what you said, is to make it more clinically relevant, which was one of the bullet points and not on some rare disease like Cowden's disease or something like that, which is I think what you're really sort of getting at. So that's one part. The other part is to make it more modular. So if most of your practice is IBD, your exam would be enriched with IBD questions. But since, in general, in many practices there may be some core principles in gastroenterology that all of us should know, those types of questions would be on there, but it wouldn't be sort of the deep-down dive questions that you're going to refer to your colleague for complex pancreatic cysts or something like that. It might be what is pancreatitis or identifying an individual with cholangitis as a basic question, but then the more complex questions would be moved to a more modular format. And although I'm not a GI doctor or a hepatologist, I found those questions very useful, which further punctuates that case-based learning is fantastic, and I think more of our CME programs should have this type of learning in addition to standard didactics. Do we have any sense of the timeline for this work on developing new longitudinal types of assessments? David? I think the answer is, I think I remember the year, but we have an ABIM person here. So David, do you want to say what the... I mean, we've talked about it at the board meeting we had in the fall, where it's a big part of, I think, what we're going to talk about as well as some other things at our spring meeting, but it does take a process. And I think, I mean, I'm hoping for 2021, but I don't know. That's my personal hope. assessment. How recently will you be But I get the sense that, so you have this sort of ten year cycle, and for me the ten year cycle was six months before I had to recertify for the GI test, I started to freak out probably before then, but I started my process of learning, I went to a board review course, I started studying a lot of my other activities that I would do on nights and weekends I couldn't do, there was a grant I couldn't submit during that time, so I put a lot of time and effort into studying, and then I figured that's fine, I decided not to do the two year knowledge check-in because I didn't want to have to be burdened with my sort of way that I approach things every two years to be worried about it, so I said I'll just worry about it again in nine years and six months, and then I'll just sort of blast it through. I was very good at GI conferences for about two months, I was answering questions and making comments and doing things, and then those things started to drop off, and then probably after about a year, a year and a half, I was back to where I was when it came to the stuff that I don't do, which is the non-liver stuff. If I were to map out the amount of time I spend during the ten year exam, and if I were to spread that out over ten years, 52 weeks a year, I tried to figure out if I spent ten or fifteen minutes a week, would that add up to the same amount of time, and the answer is probably, for me anyway, because I tended to study a lot, but my anxiety would probably not be that bad, and I wouldn't have to put off a lot of other things, so I'm not sure. Obviously every individual learner, I'm not sure if you decide how much time over a ten year period you have to put it in, will you put it in all at the end, and you do like what Mark is doing, is he's had to go to the course, and he had to do a lot of other things, or whether you sort of spread that out in a lot less stressful pathway. I do hope that for me, if I'm going to maintain both GI and transplant epitopology, which my hospital tells me I need to do, I can't just do transplant epitopology, I know I could do that, but my hospital won't let me do that, because they want me, I'm in the GI division, so I have to keep that up. I'm hoping that my number of questions won't be that much more to maintain both, because right now I have to study for both boards, and I'm hoping that the questions will be a lot more focused in my area, and will include some basic GI things, but probably I'm going to be able to answer those anyway, because they're sort of core things that I've known, and I've been a gastroenterologist for 30 years, so I'm not too worried about that part. So I think my anxiety is going to go way down, and I'm going to have better management of my time, and again, you can easily do these, the hope is, is that you can easily do them, it won't take that long. And I would say, provide the feedback, there's feedback about how many questions you think it could be. I mean, I think we'd all agree 500 questions every quarter would be too much. Probably one question every quarter is too little, but maybe provide some feedback of what you think would be, you know, a reasonable amount of questions to answer over what time period. I think this is what the kind of guidance we're looking for. Per quarter is certainly more appealing than per week. Well, you don't have to answer, my understanding is that you don't have to answer them. So there is a certain amount that you have to answer periodically, so it could be by the end of the quarter, if you decide to, you know, build them all up, and you're just going to, you know, spend a Friday afternoon and knock out one or two months worth of questions, you'll have that as an option. So it's not like, but you will have to answer a certain number of questions during certain parts of the year, and you will have to answer a certain number of them correctly. Now I often kind of wonder, too, where you are in your cycle. So if I decided I took my exam, I'm going to wait until my ninth year, instead of having to study, I'm going to go ahead and I'm going to enter the longitudinal pathway at year nine, and then at that point I'm going to forego my 10-year exam, but I'm going to say I'm going to lock myself into the longitudinal pathway, in which case I have to continue to do that for the time that I want to continue to practice to answer those questions. And so I don't think a lot of those details are worked out about when you have to sort of make that decision. I would imagine the screenshot that Ryan gave, he had the two-year exam, you had the 10-year thing, and I would imagine eventually there might be another box next to it saying that you have elected to enter the longitudinal pathway, and hopefully with some, that little eye box that would tell you if for some reason you decide it's not for you, then you would have the opportunity to go back and do something else and what that would entail. But again, that's just my personal opinion, but I think that's what probably needs to happen to give people flexibility. I'll just add two points, maybe three. One is that of all the ABMS's member boards, none require questions on a weekly basis. Most are looking at quarterly or annually for a timeframe to answer questions and are looking at data on when physicians are doing that all at once, once a day. And looking at the boards that have implemented longitudinal assessment programs so far, there are a couple of different models to go on how to phase it in. The boards have heard the strong message to pilot these programs to make sure that they're kind of striking the right balance and being responsive to the physician community. So I would expect a wave of pilots to come in based on when the 10-year cycles are up. Some boards are also offering kind of low burden. You can try a longitudinal assessment program before committing fully, so there might be an option like that. Of course, I'm just talking about what other boards have done. So there are a couple of different models that ABM and others can look to. I think the collaborations with ACC and some boards are, non-ABM boards are also partnering with their specialty societies who already have educational platforms up and running. And those have allowed rapid deployment of some of these systems. So there's ways to get these going without just an extended timeframe as well. I just have a comment. I think that it's all great that we're trying to lessen the burden of these high-stakes exams that we are used to, but I think the next step for us, in addition to what's being proposed in terms of just keeping it down and lower stakes and spreading it a little bit longer over the year, is the fact that what Rich was bringing up, well, why do we have, as transplant hepatologists, have to maintain two certifications that we don't really practice in? And so I said this yesterday in the committee, and I'll say it here. We gotta get someone to advocate for us to say to the payers, you should not be requiring a full gastroenterology certificate from us if we don't really do anything other than simple scoping in our liver patients and full hepatology practices. For those who are practicing both, sure. But for us who see less than 1% of GI patients in our clinics, I think it's a huge burden to go into gastroenterology recertification. So I just want to say that here, because if we have anybody listening here that can work on advocacy, I think that's an important thing to take up to the payer system, and eventually maybe ABMS and ABIM can have some say on that in the future. So just from the ABMS perspective, when and whether a sub-special, excuse me, primary certification should be required to be maintained when a physician has a sub-specialty certificate is something under active discussion within and among our member boards, striving for consistency, and particularly in the case of co-sponsored certificates, it doesn't make sense that if you're sponsored by multiple boards for one sub-specialty certificate that you might have to keep your primary certification in one but not the other. There are cases when keeping both makes sense clinically. But the boards are talking about this, taking a fresh look at when primary certification is required. The physicians who are in ABIM can correct me if I'm wrong, but I believe sub-specialty certificates, that ABIM no longer requires maintenance of the primary certificate. Okay, I'm getting nods from the back, so that's good. I can't speak to payers, but that's at least the conversation under me within ABMS. So for me, it's my institution. To me, it's not, now they've not told me that it's because of the payers. That may be their reason, but they told me, you're part of GI division, suck it up, and you have to do both. Yeah, it would probably require modification of what the content of the transplant hepatology certification to include, you know, screening colonoscopy or endoscopy related content. Because right now, in order to be boarded in transplant hepatology, you have to have completed a GI fellowship and hopefully learned all those skills and passed the GI exam and it's to do those basic things. My understanding is that it's really up to you and your hospital about what they require. So you may need to go and lobby them on your behalf. If you don't want to maintain the GI certificate, I sort of said, why do I have to do both? And they told me, because you do and we're not going to change. Because I'm a member of the GI division. At my place, I was told it was the hospital. That was their excuse. Now, I don't know what they did, so. I would just add a comment. The MBPAS solved all those problems. I'm now boarded in transplant hepatology GI and now again in internal medicine. It was painless. Well, I can tell you, I, you know, I recertified once in internal medicine after 10 years and that was a very difficult because I really am far out from that. And so I just decided, so my hospital, I decided I wasn't going to keep up my internal medicine certification. I was just going to keep up my GI and transplant and my hospital had no problem with that. Even though I attend on the wards, it's primarily as a gastroenterologist and hepatologist. So again, I think it's my sense again is that it's very hospital dependent on what they want you to do. I've spoken to people who have said, oh no, my hospital wants me to have all three. And I said, I, oh, I feel sorry for you. You should maybe think about, you know, moving, but it's, it's, again, it's up to them, the individual. So yeah, Katie, I just wanted to remind everybody in the room that the module that Heather went over is actually on liver learning live. And so go to liver learning, go to ASLD's website and deliver learning. And it is the hepatology self-assessment program. So it's simply named. And if you take that, then you get more credits and MOC points. And I just want to remind you, if you have any difficulties finding it, we have staff in the tech bar down near the registration area. So please see them. Great. And I think we're about at time. I want to thank all of our speakers and, oh, yes. Is there any push to giving credit, MOC credit, for publication of our MOOCs? Oh, that's a good question. Publication costs. Yeah. Giving, yes. MOC for publication. Yes. That's part of the wide door approach that, that our boards are adopting is, it's more and more situations like that for MOC credit. So, I mean, I think that the MOC opportunities now are far greater than they used to be. And, but my sense is that when I talk to people who don't have them, it's because they really haven't made the effort to do the extra steps when they get their CME in order to look for it. It's not that they're not available. It's just that they're not thinking about it. Okay. Thank you.

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