It goes through all the do not disturbs anyway. So I have nothing to disclose. So I'm going to talk about the different pathways to becoming a hepatologist or becoming certified as a hepatologist. But I want to first talk about why you should get additional training and be certified in the first place. So right now there's two different pathways in the United States to be certified. There's the standard training, which is three years of GI followed by a year of hepatology. And there's the pilot pathway, which is training in hepatology during your GI fellowship. Anybody here familiar with the pilot pathway? Good. I've got some people raising their hands. I will get back to this a little bit later. But first of all, hopefully you have some idea of what your career path is going to be like. And if you don't, that's OK. That's why you're here. Because if you're at the liver meeting and at the career development workshop, you're interested in a career in hepatology. But once you finish your training, there's a lot of different ways you can differentiate. And you're going to hear from people at this workshop that are doing these different career pathways. Academics is sort of the traditional where a hepatologist usually lives. But that's not really the case anymore. There's a lot of people doing VA-based care, community-based care, which could be private practice or you're an employee of a hospital or health system. You can do basic science as an academic career. You can do clinical research in academics or in community-based. And academics could be primarily clinical as well. So there's lots of things you can do. And you should try to structure your training to achieve the goals that you want in your career. For GI program requirements, according to ACGME, it has to be a 36-month program. But 18 months of those are clinical experiences. So there's a lot of room to do a lot in your GI fellowship that aren't just clinical. And five of those 18 months are hepatology. So you are going to learn about hepatology and become competent as a general hepatologist in GI fellowship. And so you might ask, why do I need additional training beyond GI? And you might ask, well, what is a hepatologist? Is a hepatologist really different from a gastroenterologist who mostly sees liver patients? This was the way, primarily, that people were trained in hepatology before we had a specific fellowship. And we actually, over a decade ago, did a workforce study that was commissioned by the AASLD to try to define this. And our original definition was someone who spends most of their time seeing liver patients because there wasn't this board certification and specific training in hepatology at the time. And what we found was that, indeed, a hepatologist is distinct from a gastroenterologist who sees liver patients. A hepatologist is someone who has additional specific expertise and competencies that differentiate them from a gastroenterologist. And actually, gastroenterologists refer their patients to hepatologists, whether those are patients in need of transplant, but also complex liver patients, decompensated cirrhosis, complex autoimmune hepatitis, those sorts of things. So we named our specialty transplant hepatology. And that led to a board exam and an ACGME pathway with program requirements. So then you might ask, well, is a hepatologist different from a transplant hepatologist? Why is it called transplant hepatology? Why do I need to do another year of training? Why do I need to be certified? I'm going to hopefully try to answer some of these questions. What if you aren't interested in being in an academic institution or you don't want to work in a transplant program? Why do you need to be a transplant hepatologist beyond just a hepatologist who's GI trained? And I think part of the problem is that the name transplantology has kind of deterred a lot of people. It's been a little bit misunderstood about what is really involved in that sort of training. You may not be aware of the benefits of actually being certified. And I'll acknowledge that there haven't been a huge amount of benefits beyond just GI certification, but I think that's changing. You may wonder, you know, if I want to be a hepatologist but I don't really want to take care of transplant patients, do I need that additional training? So I think, this is my personal opinion, but I think that our specialty maybe did a bit of a disservice to furthering our specialty by naming it transplant hepatology. It's trying to differentiate a specially trained hepatologist from a gastroenterologist. It's saying this is what makes us different from gastroenterology. And I think it was a little bit of a reassurance to the GI community. We're not taking hepatology away from you. We're still part of you. And it's still true. In order to be certified in hepatology, the two pathways I showed in the beginning have to go through GI. You have to be certified in GI before you can get certified in hepatology. And I don't think that's changing, not anytime soon. There's certainly people that think that that's not necessary, that we should be able to go to hepatology straight from internal medicine. I'm not going to really go into that too much, but I do think the GI training is important in terms of job security and keeping your salaries up and things like that. But I think it was pretty easy at the time to define hepatology along transplant lines. It's pretty specific. That's what makes us different. But really, there's a lot more to it. You can't really be a hepatologist without knowing how to manage a transplant, but there's so much more to what we do. I think if you aren't interested in a transplant career, you really need to be able to take care of the full spectrum of liver disease from pre- to post-transplant, even if that's not what you're doing on a day-to-day basis. You're going to have to explain to your patients what that process looks like. You have to know what patients are going to be going down that process, down that path, and to really counsel them. I think we should maybe take a cue from our cardiology colleagues. They have a lot of different subspecialties. CGI has one, and that's transplant hepatology. They named one of their subspecialties Advanced Heart Failure and Transplant Cardiology. Maybe what we should be doing is renaming our specialty to really give it the sense of what it is that we learn and what the curriculum of transplant pathology really is. I promised I would try to explain why I think certification is important. There are certain advantages to being certified. This is by the American Board of Internal Medicine. Of course, it demonstrates in a very concrete way your expertise to employers, to colleagues, to patients, and to the public. As I mentioned, it might actually get you a nicer salary than if you're not certified. It opens the doors for leadership positions. The only leadership position I know that requires certification is to be on core faculty for a transplant pathology fellowship. You can be the medical director of a liver transplant program or the UNOS primary physician and not be certified, but I think more and more that's a desired credential. I think it'll give you a competitive advantage in the job market. You may be hearing at this meeting about workforce issues. We have a big workforce deficit. The liver disease is growing, and we don't have enough hepatologists to meet that demand. That might lend itself to, well, the job market's wide open. That is true in general. There's a lot of jobs out there for hepatologists, but it's not evenly distributed throughout the country. There are parts of the country that are saturated with hepatologists. They tend to be in the places where people want to live and work, big cities and academic medical centers. How are you going to make yourself different from how you're going to be competitive against other hepatologists applying for those same jobs? I think certification and additional training is really where to go. Some disadvantages. It may require additional training, and not necessarily. I've described the pilot program where you can get that training in the same amount of time as GI, but if you do choose to go on to an extra year of fellowship, it's one more year. I hear some people say, well, if you're not willing to do that extra year, then you're not really committed to a hepatology career. I don't believe that. I think once you've been through all these years of training, and you're ready to get into the workforce, all of your friends who aren't physicians have been in the workforce and earning a nice salary for years. That one year is a lot, and I recognize that, and that's part of the reason we started the pilot program. It is an additional certification exam, and we're all sick of taking certification exams, but it is one more, but it may not be additional MOC or maintenance of certification exam. So ABIM allows you to maintain your hepatology certification and let your internal medicine and your GI certifications lapse. Be careful, though, because your hospital credentialing process might require you to keep GI certification, so that's something you have to look into. So do you need three years of GI and one year of transplant hepatology training? That really depends on you and your career goals. Some advantages of doing that pathway, three years plus one, let's be honest, some people learn at different rates, and you may need those three years to really become competent in gastroenterology, and you really don't want to, you shouldn't actually be able to graduate from a GI program without being competent, but even though your goal is to be a hepatologist, you still want to be a competent gastroenterologist first, or at least concomitantly with your training in hepatology. So you might need those three years to actually go through the milestones and get there. Even though we're in this era of competency-based medical education, where we're trying to remove time as a primary criterion for competence, that doesn't mean that time isn't important. So experience is really important, and experience takes time, and sometimes people want to get that experience while they're in that protective environment of a fellowship, and so doing three years of GI and then an additional year of hepatology can get you that extra experience, and there's nothing wrong with that. I think the most important reason why you might want to spend three years in GI and then a year in hepatology is those extra 18 months that I showed in the beginning really can give you time to do a lot of things. And especially if you want a research-focused career, you really can't do it all in three years. You're going to need some time to gain the skills that you need to eventually become independently funded. You might also want to get an additional degree, an MBA or another master's degree, and that can be done during GI fellowship in certain programs. Disadvantages to doing it that way? Well, if you're really focused on a clinical career in hepatology, maybe that extra year of GI is just more than you really need or more than you want to do, and maybe you can get to your career a little bit faster if you can go through it in three years. And we recognize this might be a deterrent to actually getting that additional training that you need because of that additional year. So I mentioned the pilot program. There's a lot of people in the room that have heard of it. So this started in 2012. It was a competency-based pilot that we applied to the American Board of Maternal Medicine, ABIM, to do this sort of experiment to look at competence as opposed to time. Can we actually get people certified, competent and certified in GI and hepatology in three years instead of four years? And so far, we've trained 91 fellows in this program. There's 18 in the current class, and this is in its eighth year. And those fellows represent a quarter of all hepatology fellows who have graduated in that period of time. They come from 37 programs. That's over two-thirds of all the accredited transplant hepatology programs in the country. And so because of the sheer numbers, which is important to ABIM, when you see that the majority of people, or not the majority, but a large proportion of people taking their exam are going through this program, that speaks to them. But more importantly, we did surveys, and we looked at board pass rates, and we found that the standard fellows, the four-year pathway, and the pilot fellows were essentially equivalent in terms of the kinds of jobs they were getting, their participation in research, their satisfaction in preparation for their practice, and also board pass rates. So every one of the pilot fellows that took the GI exam passed, and everyone that took the hepatology exam passed. So because of that, ABIM just recently approved this pathway as a permanent pathway for training. So I changed my slide here from what you might have gotten. It says may be available, because ABIM approved this to be available in July 2020 for anybody who's currently a second-year GI fellow and will be a third-year GI fellow next year. But the ACGME process of actually approving new requirements might take longer. We're trying to push it through to get it approved by July, but it might take an additional year. And if that happens, we're prepared to do the pilot one more year to give everybody who wants to do it an opportunity. ABIM requirements are that the training has to be at the same institution. They're not going to permit transfers just for the transplant hepatology training portion. They're not going to approve this retroactively. So if you want to do this, it's either through the pilot that exists now or through the new pathway that will exist hopefully starting in July. As I pointed out, I think if you're going to do your training in a shortened period of time, it's ideal if you're interested in a clinically-focused career. It's not probably ideal for someone who wants a research-focused career. I think you need more time for that. So hopefully, I know I'm about to run out of time, and I just want to go through a little more quickly the practical aspects of applying for training. So hopefully I've convinced you that you should do additional training, whether it's in three years or four years. If you want to know where you can do that training, I would recommend that you go to the ACGME website, acgme.org. At the top right, there's a button that says Search Programs and Institutions, and that'll give you this page. In the left column, there's List Programs by Specialty, and then you pick Transplant Pathology, and then you get this list. So it's a little bit convoluted, and that's why I go through it. But this will give you the list of every current accredited program in the country and all the contact information. So that's a great place to start. And even if you want to do the pilot program, you've got to go to a GI fellowship that has one of these transplant pathology fellowships at the same institution. If you're going to do the fourth year, you need to start applying about 18 months before you're going to start training. So if you're a current second year GI fellow, that's about now, and hopefully you've got some meetings at this meeting to start talking about that with people. Definitely go to the program websites. There is no match. There is no standard application process. So every program is going to have a different application. You want to go to their website, download it, see what their requirements are, contact the programs individually. Definitely use your program directors and your mentors to help steer you toward programs that might be appropriate for you. They have some personal connections that can help. Every program is going to want to see a CV, letters of recommendation, personal statement. Some may want procedure logs and transcripts. If you're doing the dual certification pathway, definitely talk about this with your GI program director as soon as possible, early in your first year ideally, even during interviews if that's the part of the process you're in. I think telling GI programs that you're interested in this dual pathway may potentially open doors and also you want to make sure that it's going to be available to you at that program. Just because they have a transplant hepatology program doesn't mean they're going to be offering the dual pathway. The decision to be in the dual pathway should come sometime during your first year. The pilot only allows you to start hepatology in your third year of GI fellowship. One difference between the pilot and the dual pathway that will be approved by ABIM and ACGME is we're going to allow training to start in the second year to make it more of a truly blended training program. We still think that the first year should be all GI. What are some other factors that can help you decide on a program? Geography I think is a big one. Some people have restrictions on where they're willing to go or able to go, maybe because of a spouse or partner. I think beyond just restricting your options, it actually can make it quite a lot easier to decide where you want to apply. That's the first thing to look at. I think it's really important to look at mentorship and research interest and go where that's going to be fostered. Think about where you want to practice. Not everybody stays, you certainly don't have to stay where you train, but a lot of people stay in the same institution or the same city. Starting to develop that network in training is a good idea. I think transplant size is really important. The graph here shows there's a huge variability in liver transplant program size throughout the country. Even if you don't want to be a transplant pathologist or you don't want to work in a large transplant program, I think training in a large transplant program is really important because it's going to give you that experience. The more you see in your training, the more comfortable you're going to be to just handle anything when you get out of training. Again, if you're interested in the dual certification pathway, make sure that's available where you're applying. The key takeaway slide is that hepatology requires specialized training and may require an additional year of training beyond GI fellowship. Transplant hepatology, the name of our specialty I think is a misnomer because transplant training is needed to develop the expertise in the full spectrum of liver disease. The transplant hepatology fellowship also encompasses training in advanced liver disease and the transplant hepatology fellowship is important whether or not you're interested in a transplant-focused career. There are two pathways to transplant hepatology certification. There's the fourth-year fellowship and very soon the dual GI transplantology certification formerly known as the pilot. Those with a clinical hepatology career interest may prefer the dual certification pathway and those with academic or research-focused career interests and other interests should use the third year of GI fellowship to develop the necessary skills for their career. I'd be happy to take questions later or you're always welcome to email me. Thank you very much. Thank you.

hepatologist

certification

training pathways

competencies

transplant program