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Gastroenterology-Transplant Hepatology Pilot Program

The following information was submitted by the Gastroenterology-Transplant Hepatology Pilot Oversight Committee

For additional information about the pilot, visit the American Association for The Study of Liver Diseases or contact Oren Fix at orenfix@gmail.com.

FAQs

  1. What are the benefits of the pilot?
  2. For individual fellows, a benefit is the use of a competency-based model to reduce training time required to become certified in both Gastroenterology and Transplant Hepatology. These fellows are likely to enjoy increased attention from program directors and other core faculty. Individual training programs benefit from a highly motivated and focused fellow. Many gastroenterology fellowship programs are seeing an increase in applicants with an interest in hepatology who are seeking programs that offer the pilot pathway. Transplant hepatology is one of the first specialties to formalize and implement competency-based training. Individual fellows and programs benefit from pioneering this new training paradigm by advising the AASLD and ABIM about best practices. Lessons learned from the pilot will undoubtedly be used in other competency-based frameworks. If successful, the pilot pathway will become an accepted training track toward Gastroenterology and Transplant Hepatology certifications. Most importantly, employers, patients and society will benefit from a group of providers who have demonstrated competence in gastroenterology and transplant hepatology through a rigorous training program utilizing innovative assessment methods and established competency standards.

  3. Did ACGME issue an official approval letter for the pilot?
  4. The pilot functions via ABIM-granted individual exceptions to training and therefore does not require IM RRC approval.

  5. How will the Transplant Hepatology pilot affect recruiting, call schedules, continuity clinics, rotation schedules, funding, etc. within the existing 3-year gastroenterology fellowship?
  6. These concerns are program-specific, and cannot be answered across the board; it will be an ongoing learning process. Although each individual program has “specifics” that may not be shared by other programs, open communication between program directors will be beneficial to share experiences and preempt problems, as well as enhance problem-solving of such issues across programs. Going forward the experience/data gathered from the leading pilot programs will constitute the threshold on which joining programs may build and from which they may benefit, to better plan for and execute the pilot year.

  7. Will fellows enrolled in the Transplant Hepatology pilot be eligible to sit for the ABIM Transplant Hepatology Certification Examination?
  8. Yes. Candidates will be informed by ABIM of their enrollment in the pilot and receive documentation that they are being granted an exception to existing ABIM training requirements that will allow them to sit for certification in both Gastroenterology and Transplant Hepatology upon successful completion of the pilot.

  9. When can a pilot fellow take the ABIM Gastroenterology and Transplant Hepatology Certification exams?
  10. The pilot fellow will be eligible to sit for both specialty certification examinations after completing the 3-year pilot (third year of gastroenterology). As per current requirements, the fellow cannot sit for the Transplant Hepatology exam until passing the Gastroenterology exam. Because the Transplant Hepatology exam is offered every other year, in some cases, the pilot fellow will need to wait two years after completion of training to take the Transplant Hepatology exam. If requested, ABIM can provide a letter attesting to completion of the unique training pathway while the fellow is waiting to take the exam if needed for prospective employers.

  11. Can a physician who completed two years of gastroenterology fellowship training and one year of transplant hepatology training outside of this pilot program become certified in Transplant Hepatology?
  12. No.

  13. Does the institutional GME office need to approve the pilot?
  14. This may be an institution-specific issue, but our best advice is to involve the GME office, since the pilot can be seen as a new training track within gastroenterology.

  15. My gastroenterology program is not currently associated with an ACGME-accredited transplant hepatology fellowship. Can I participate in the pilot program?
  16. No, unless your institution applies for accreditation for a transplant hepatology fellowship program through ACGME.

  17. My gastroenterology program is not associated with an accredited transplant hepatology fellowship. Can I transfer to another program after the second year in order to participate in the pilot?
  18. No.

  19. What do I need to do to prepare for the pilot?
  20. Inform your gastroenterology fellowship program director as early as possible of your interest. You and your program director will be responsible for ensuring that most clinical gastroenterology requirements are completed by the end of the second year and that you are on a trajectory to achieve competency in gastroenterology by the end of the third year, taking into account that the third year will necessarily be focused on development of competency in transplant hepatology. In practice, this means that most, if not all, clinical gastroenterology requirements must be completed by the end of the second year. It is not necessary to include five months of general hepatology training in the first two years but some hepatology training is required before entering the pilot year. (See “Does the pilot fellow need to complete the five months of required clinical hepatology training during the first two years of gastroenterology fellowship before beginning the pilot year?” below.)

  21. How do I enroll into the pilot?
  22. If your program is selected as a potential pilot fellow, you and your program director will need to formally apply to the pilot steering committee program between February 1 and March 31 of your second year. Application materials can be obtained from your transplant hepatology program director. The pilot steering committee will review the application and issue formal approval, at which time your name will be forwarded to ABIM for tracking and certification purposes.

  23. If a program doesn't apply now, can it participate in the future when an interested fellow is identified?
  24. Yes. A program should not apply unless and until it has an appropriate fellow. Programs and fellows are considered and approved on a case-by-case basis each year.

  25. What programs have participated in the program already?
  26. The following programs have participated or are currently participating in the pilot program. These programs may or may not participate in future years, depending on whether they have an appropriate fellow. Many other programs are eligible to participate in the future, provided they have an ACGME-approved gastroenterology fellowship program and an ACGME-approved transplant hepatology fellowship program.

    2012-13
    Johns Hopkins Medicine – Baltimore, MD
    Mount Sinai Health System – New York, NY
    Virginia Commonwealth University – Richmond, VA
    University of Pittsburgh – Pittsburgh, PA

    2013-14
    Case Western Reserve University – Cleveland, OH
    Thomas Jefferson University – Philadelphia, PA
    University of Wisconsin – Madison, WI

    2014-15
    Beth Israel Deaconess – Boston, MA
    Case Western Reserve University – Cleveland, OH
    Mount Sinai Health System – New York, NY
    Thomas Jefferson University – Philadelphia, PA
    University of California, San Diego – La Jolla, CA
    University of California, San Francisco – San Francisco, CA
    University of Cincinnati – Cincinnati, OH
    University of Florida, Gainesville – Gainesville, FL
    University of Miami – Miami, FL
    Virginia Commonwealth University – Richmond, VA

  27. What are the reporting requirements for the pilot program?
  28. The gastroenterology and transplant hepatology program directors and the pilot fellow will be required to complete at least two surveys during the course of the pilot. The Clinical Competency Committee will need to complete an end-of-year summary statement that includes the types and frequency of assessments used in reaching an evaluation. Pilot fellows must agree to some modest reporting expectations following their graduation from the pilot program (e.g., nature and location of subsequent faculty position, whether the graduating fellow remained in the field of transplant hepatology, etc.). Core faculty will also be asked to complete at least one survey about their experience.

  29. In what gastroenterology-specific activities can the pilot fellow participate during the pilot year?
  30. We support the experience of the pilot fellow to ensure continued exposure to gastroenterology so that the fellow can continue to work toward achieving competence in gastroenterology and to facilitate passing the ABIM Certification examination. These activities may include attendance and participation at gastroenterology conferences, participation in gastroenterology continuity clinic and Gastroenterology call.

  31. Is the pilot fellow required to attend all gastroenterology and transplant hepatology conferences?
  32. No. The required attendance at conferences should not increase, but should be blended to reflect the required exposure to each specialty.

  33. What gastroenterology-specific activities should be minimized/avoided during the pilot year?
  34. The pilot fellow should not participate in therapeutic endoscopy procedures or consultations and should not act as “chief gastroenterology fellow” during the pilot year.

  35. Does the pilot fellow need to complete the five months of required clinical hepatology training during the first two years of Gastroenterology fellowship before beginning the pilot year?
  36. No. However, we expect that the fellow will engage in some general hepatology clinical training during the first two years of fellowship.

    There should be sufficient exposure to hepatology to gauge the fellow's level of interest in Transplant Hepatology, to be sure the fellow will commit to training in transplant hepatology and will remain in the field. There should be sufficient exposure to hepatology to provide the transplant hepatology program director with an indication of how the fellow will perform in the pilot program and that the fellow is appropriate for the pilot. In practice, we recommend at least two-three months of general hepatology clinical training before entering the third year.

  37. What about scholarly activity?
  38. We recognize this trade off between achieving clinical competency and pursuing scholarly activity. The pilot fellowship program is an intensive clinical track that will substantially decrease the time available to focus on research and other scholarly activities. This underscores the importance of selecting the appropriate fellow for the pilot program. Fellows who wish to focus on research may not be appropriate for the pilot program and should remain in the traditional track by completing three years of gastroenterology training before pursuing transplant hepatology training. This includes fellows funded by a T32 grant as there will not be sufficient time to fulfill requirements for research training and clinical gastroenterology training in a two-year period prior to starting a pilot year. Pilot fellows must still fulfill the ACGME requirement to participate in research or other scholarly activities and this requirement is now included in the new ACGME Reporting Milestones as a distinct subcompetency for all internal medicine subspecialties.

  39. Can I participate in the pilot if I am on a T32 training grant?
  40. No. See “What about scholarly activity?”

  41. How will the pilot impact the 4th year transplant hepatology fellowship?
  42. The pilot year is in the “testing phase” and is not currently replacing the 4th year. The pilot was not designed to replace the 4th year track and may continue to co-exist in programs that have the capacity to train two or more transplant hepatology fellows per year. It is not clear at this point if the demand for 4th year fellow positions will continue in the future or whether the pilot fellowship track will eventually replace the traditional pathway.

  43. What is the Clinical Competency Committee (CCC)?
  44. All sites participating in the pilot have been required to create a Clinical Competency Committee (CCC). This is now an ACGME requirement for all training programs. See the transplant hepatology ACGME program requirements for a description of the CCC. The pilot program requires an end-of-year summary statement issued by the CCC that includes the types and frequency of assessments used in reaching an evaluation.

  45. Why is the Gastroenterology CCC chair required to sign the pilot application?
  46. One of the most important criteria for applying to the pilot program is that the program must attest to the applicant's developing competence and the trajectory of the applicant toward competence in gastroenterology by the end of their third year. The CCC is in the best position to attest to the applicant's competence and we therefore want to emphasize the importance of the role of the gastroenterology CCC chair in this process.

  47. What is an EPA?
  48. “Entrustable Professional Activities (EPAs) are those professional activities that together constitute the mass of critical elements that operationally define a profession” (ten Cate O, Scheele F. Academic Medicine 2007;82:542-7). Supervising faculty assess the competence of a trainee through direct observation of the performance of these activities. Each EPA represents various competencies and milestones of professional development. Use of EPAs is the cornerstone of assessment within this competency-based medical education pilot.

  49. Is there a transplant listing meeting EPA?
  50. No. This was considered at the time the pilot program was initiated, but the competencies and milestones required to competently lead a transplant listing meeting are now incorporated into the new EPA “Evaluate and manage the pre-transplant patient”.

  51. What is CTM-3?
  52. CTM-3 is a validated instrument developed by the Care Transitions Program at the University of Colorado. It is administered as a questionnaire to patients and measures the extent to which patients are being prepared to participate in post-hospital self-care activities. The questionnaire is copyrighted, but free for use. CTM-3 is a required assessment tool for the pilot.

  53. How does the CTM-3 assess fellow competence?
  54. We recognize that the discharge process of a pre- or post-transplant patient is complex and involves many people and systems. Although the pilot fellow may not be directly involved in the discharge process, this transition is so important to the care of a pre- or post-transplant patient that it is helpful to examine the role of the fellow in this complex system. If the CTM-3 reveals a problem with this transition, it is important for the fellow to reflect on his/her role and where he/she can make changes to improve care during the discharge process. In addition to teaching about the importance of self-reflection and systems-based practice, the CTM-3 can spark ideas for QI and patient safety projects.

  55. What is Mini-CEX?
  56. The ABIM Mini-Clinical Evaluation Exercise (Mini-CEX) is a 10-20 minute direct observation assessment or “snapshot” of a trainee-patient interaction. The faculty member provides timely and specific feedback to the trainee after each assessment of a trainee-patient encounter. The Mini-CEX need not assess a complete patient encounter and can be used to assess a specific part such as counseling, which may be most appropriate for fellows at this advanced level of training. Mini-CEX booklets can be ordered directly from ABIM free of charge. The Mini-CEX (pdf) can be distributed for demonstration during faculty workshops, staff meetings, orientation and training sessions. The pilot requires that Mini-CEX be administered at least quarterly.

  57. Is there a Transplant Hepatology In-Service Examination available?
  58. Not yet, but efforts are underway to create such an exam which will be administered for the first time beginning in the current academic year.

  59. What is the Hepatitis C PIM?
  60. ABIM PIMs Practice Improvement Modules® are Web-based tools that guide physicians through a review of patient data and support the implementation of and/or reporting on a quality-improvement (QI) plan for their practice. The Hepatitis C PIM is a required activity for the pilot. It requires the fellow to abstract at least five charts at three months and nine months into the pilot as a means to demonstrate the trainee's ability to analyze, improve and change practice or patient care.

  61. Is simulation a required assessment tool?
  62. Fellows must participate in training using simulation (IV.A.3.b. of the ACGME Transplant Hepatology Program Requirements). Simulation does not require the use of high-tech models and can be as simple as simulating a patient case presentation with the trainee. Liver biopsies lend themselves well to training and assessment through simulation, but this is only one example of the use of simulation in transplant hepatology training.

  63. Are portfolios required for the pilot?
  64. Portfolios are not a required assessment tool for the pilot or for transplant hepatology training in general. Portfolios can be a useful assessment tool in both undergraduate and graduate medical education and can be used as a tool for trainees to record their accomplishments, reflect on their experiences and obtain formative feedback. In practice, portfolios may be difficult to implement in fellowship training. There are many platforms available and we are unable to recommend a specific platform.

  65. Where can I get more information?
  66. Talk to your transplant hepatology program director or contact Oren Fix at oren.fix@ucsf.edu.