The following information was submitted by the Gastroenterology-Transplant Hepatology Pilot Oversight Committee
- What are the benefits of the pilot?
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.
- Did ACGME issue an official approval letter for the pilot?
The pilot functions via ABIM-granted individual exceptions to training and therefore does not require IM RRC approval.
- Are there other ABIM pilot programs?
Yes. ABIM has approved three competency-based medical education pilots including gastroenterology/transplant hepatology. The other pilots are geriatrics/palliative medicine and internal medicine/cardiology. All three pilots differ substantially in goals and structure but all share the goal of using competency-based assessments in innovative ways.
- How long will the pilot last before it will become a standard training pathway for gastroenterology and transplant hepatology?
This has not been determined. A final decision about the fate of the pilot and whether it should become a standard training pathway will take several more years, but likely less than 10 years.
- How will the Transplant Hepatology pilot affect recruiting, call schedules, continuity clinics, rotation schedules, funding, etc. within the existing three-year gastroenterology fellowship?
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.
- Will fellows enrolled in the Transplant Hepatology pilot be eligible to sit for the ABIM Transplant Hepatology Certification Examination?
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.
- When can a pilot fellow take the ABIM Gastroenterology and Transplant Hepatology Certification exams?
The pilot fellow will be eligible to sit for both specialty certification examinations after completing the three-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.
- 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?
- Does the institutional GME office need to approve the pilot?
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.
- My gastroenterology program is not currently associated with an ACGME-accredited transplant hepatology fellowship. Can I participate in the pilot program?
No, unless your institution applies for accreditation for a transplant hepatology fellowship program through ACGME.
- 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?
A transfer may be considered only in unique and extenuating circumstances. Requests for such an exception must be made to the Pilot Steering Committee in advance (before the application deadline) and will be considered on a case-by-case basis.
- What do I need to do to prepare for the pilot?
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.)
- How do I enroll into the pilot?
If your program has selected you as a potential pilot fellow, you and your program director will need to formally apply to the Pilot Steering Committee program during 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. This is not a competitive process; all fellows who meet the criteria will be approved.
- Can I be approved for the pilot before or during my first year of GI fellowship?
No. The criteria for entry into the pilot include a determination by the Gastroenterology Clinical Competency Committee that the fellow is on a trajectory to achieve competence in Gastroenterology by the end of the third year. This generally cannot be determined prior to the start of Gastroenterology fellowship and is best assessed late in the first year or early during the second year of fellowship. In cases where the fellow is not on a trajectory to achieve competence in Gastroenterology by the end of the third year, as determined by his/her performance by the end of the first year or the beginning of the second year, that fellow will not be allowed to enroll in the pilot program.
- Can the Gastroenterology Training Exam (GTE) be used as a selection criterion for entry into the pilot program?
No. The GTE is a formative exam used for continuous improvement of the fellow and the program. It should not be used to justify promotions or deny advancement and it should not be used as a criterion for entry into the pilot program.
- If I am accepted into the pilot, am I eligible to apply for the AASLD Advanced/Transplant Hepatology Fellowship Award?
No, currently this award is for funding for fellows during a traditional “4th year” transplant hepatology fellowship following three years of gastroenterology fellowship.
- If a program doesn't apply now, can it participate in the future when an interested fellow is identified?
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.
- What programs have participated in the program already?
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, and these are not the only programs that may participate in the future. Any program that has an ACGME-approved gastroenterology fellowship program and an ACGME-approved transplant hepatology fellowship program is eligible to participate. Check with individual gastroenterology or transplant hepatology fellowship programs directly to find out if they are offering this pilot pathway as an option.
Johns Hopkins Medicine – Baltimore, MD
Mount Sinai Health System – New York, NY
Virginia Commonwealth University – Richmond, VA
University of Pittsburgh – Pittsburgh, PA
Thomas Jefferson University – Philadelphia, PA
University Hospitals/Case Medical Center – Cleveland, OH
University of Wisconsin – Madison, WI
Beth Israel Deaconess Medical Center – Boston, MA
Jackson Memorial Hospital/University of Miami – Miami, FL
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 Medical Center – Cincinnati, OH
University of Florida, Gainesville – Gainesville, FL
University Hospitals/Case Medical Center – Cleveland, OH
Virginia Commonwealth University – Richmond, VA
- What are the reporting requirements for the pilot program?
The gastroenterology and transplant hepatology program directors and the pilot fellow will each be required to complete surveys during the course of the pilot that includes the types and frequency of assessments used in reaching an evaluation of competence. These requirements are in addition to ACGME reporting requirements including Reporting Milestones. 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.) and are required to provide contact information following graduation. The Pilot Steering Committee will also request permission to contact the pilot fellow's chief/supervisor following graduation for a brief assessment of competence after the pilot fellow has been in practice for at least one year.
- What gastroenterology-specific activities can the pilot fellow participate in during the pilot year?
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.
- Is the pilot fellow required to attend all gastroenterology and transplant hepatology conferences?
No. The required attendance at conferences should not increase, but should be blended to reflect the required exposure to each specialty.
- What gastroenterology-specific activities should be minimized/avoided during the pilot year?
The pilot fellow should not participate in therapeutic endoscopy procedures or consultations and should not act as “chief gastroenterology fellow” during the pilot year.
- 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?
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.
- What about scholarly activity?
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 Subspecialty Reporting Milestones as a distinct subcompetency for all internal medicine subspecialties.
- Can I participate in the pilot if I am on a T32 training grant?
No. See “What about scholarly activity?”
- How will the pilot impact the 4th year transplant hepatology fellowship?
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.
- What is the Clinical Competency Committee (CCC)?
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.
- Why is the Gastroenterology CCC chair required to sign the pilot application?
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.
- Which program director will be required to submit Reporting Milestones to ACGME? Will the program need to submit two sets of Reporting Milestones?
ACGME will only require a single set of Reporting Milestones for the pilot fellow, which should be completed by the gastroenterology program director (because the pilot fellow is still a third-year gastroenterology fellow). The Reporting Milestones should be completed with substantial input from the transplant hepatology program director and the transplant hepatology CCC, reflecting the competence of the pilot fellow in transplant hepatology milestones during the third year.
- What is an EPA?
“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.
- What is Mini-CEX?
The ABIM Mini-Clinical Evaluation Exercise (Mini-CEX) is a 10 to 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.
- Is there a Transplant Hepatology In-Service Examination available?
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.
- What is the Hepatitis C PIM?
The Hepatitis C Practice Improvement Module is a Web-based tool that guides physicians through a review of patient data and supports 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. Due to rapid changes in HCV treatment, the PIM was revised for the pilot in 2014.
- Is simulation a required assessment tool?
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.
- Are portfolios required for the pilot?
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.
- How many certificates should the pilot fellow receive from his/her program upon graduation?
This is up to the individual program, but we recommend two certificates reflecting the achievement of competence in two distinct specialties, gastroenterology and transplant hepatology.
- Who is on the Pilot Steering Committee?