The document discusses a Transplant Hepatology Pilot Program that aims to address the shortage of transplant hepatologists by allowing selected GI fellows to obtain competency-based training in transplant hepatology during their third year of GI fellowship. This would allow them to sit for boards in both GI and transplant hepatology after 3 years instead of requiring an additional year of transplant hepatology fellowship. The pilot program requires identification of suitable fellows, approval from the institution and boards, and coordination between the GI and transplant hepatology fellowship programs.

1. Transplant Hepatology Pilot
Richard K. Sterling, MD, MSc
Professor of Medicine
Chief, Section of Hepatology
Program Director, Transplant Hepatology
Virginia Commonwealth University
Richmond, VA

2. Objectives
• The problem
– Insufficient number of Transplant Hepatologists
• One solution
– Transplant Hepatology (TH) Pilot Program
• How to make it work
– Incorporating TH Pilot into GI training
– Impact on GI Training Programs

3. The Problem
• TH is recognized as a subspecialty in Internal
Medicine.
• Until now, candidates must complete a 3-year GI
ACGME accredited fellowship followed by a 1-
year ACGME accredited TH fellowship.
• This has resulted in only 430 ABIM Diplomats in
TH.
– Many who took the exam were existing hepatologists.
– Only 20-30 new PGY7 graduates/yr
• There is insufficient manpower to meet the
current and projected needs in hepatology.
– HCV, NASH, cirrhosis, transplant

4. One Solution
• Transplant Hepatology (TH) Pilot Program
– To obtain competency-based training in TH
during the third year to allow trainees to sit for
both GI and TH ABIM Boards after they
successfully complete 3 years of training.
– Estimated to produce 5-10 additional TH per
year (currently only 20-30 4th yr fellows/yr).
– Does not replace the 4th yr option
– May be used as a recruiting tool

5. Goals of the TH Pilot Program
• Improve patient outcomes by providing
adequately trained hepatologists
• Improve trainee outcome and satisfaction
• Increase the number of faculty trained in theory
and practice of Competency-Based Medical
Education (CBME)
• Make contribution to medical education by
testing the performance of CBME tools
• Improve public health by addressing manpower
needs in Transplant Hepatology

6. CBME Innovations in TH
• Entrustable Professional Activities (EPAs)
• Develop TH In-service exam
• Develop CBME
– Care Transition Measure (CTM-3)
– Multisource feedback instruments
– Performance measures (HCV PIM)
– Competency committee (TH PD + at least 2
TH faculty
– Develop Milestones

7. Milestones
Definition: a milestone is a significant point in
development.
- Should enable the trainee, program, and the
certification board to know an individual’s
trajectory of competency acquisition.
“A GPS tracker of the trainees level of
competency”
- They define the floor of competence
A Koteish

8. Entrustable Professional Activities
(EPAs)
 EPAs represent the routine professional-life
activities of physicians based on their specialty
and subspecialty
• When pieced together, EPAs will define the
profession of a transplant hepatologist
 The concept of “entrustable” means:
• ‘‘a practitioner has demonstrated the necessary
knowledge, skills and attitudes to be trusted to
independently perform this activity.’’
A Koteish Ten Cate O. Med Education 2005

9. The EPA
• Is part of essential professional work in a given context
• Independently executable, within a time frame & leads to
recognized output of professional labor
• Observable and measurable in process and outcome, leading
to a conclusion (‘well done’ or ‘not well done’)
• Requires specified knowledge, skill and attitude, generally
acquired through training
• Should reflect competencies
Together, EPAs constitute the core of the profession
A Koteish

10. Competency Curve over time
expert
proficient
competent
advanced
novice
training deliberate professional practice
A Koteish

11. Competency Curves for Trainee
EPA2
EPA4 EPA3
EPA1
Competence
Threshold EPA5
Justified entrustment decisions
Training Deliberate professional practice
A Koteish

12. When is Competence Reached?
 Level 1: not allowed to practice the EPA
 Level 2: practice with full supervision
 Level 3: practice with supervision on demand
 Level 4: “unsupervised” practice allowed
 Level 5: supervision task may be given
Competence threshold reached; formal entrustment decision,
“STAR” (Statement of Awarded Responsibility) is documented in
portfolio and in institutional registrars, after confirmation by three
staff members
A Koteish

13. When is Competence Reached
When a professional activity is mastered
• ...on a threshold level
• ...that permits unsupervised practice
• ...and reaches full entrustment
i.e., when
a STAR level is achieved for an EPA;
… Graduation when all EPA’s reach a STAR
A Koteish

14. Transplant Hepatology EPA: K/S/A

15. Transplant Hepatology EPAs vs. Competencies
EPAs do not conflict with or replace competencies (or milestones) but rather
complement or are comprised of competencies and milestones.
A Koteish

16. Transplant Hepatology EPAs

17. How to Incorporate TH into GI
• Must have an ACGME accredited TH Program
• Must have the right 3rd year fellow (“perfect storm”)
– Should be competent in GI by the end of year 2 and on a
trajectory to successfully complete GI by 3 years
• Golden Rule
– Third year fellows are like gold
• GI Program must be able to function with 1 less 3 rd year
fellow
– May need to adjust rotations
• This does NOT change the total number of ACGME
approved slots for GI and TH (this fellow counts twice: 1
for GI and 1 for TH)

18. How will TH Pilot Impact other GI Fellows
• Must have sufficient volume of hepatology
patients to assure that GI fellows can complete
their 5 months of meaningful hepatology
• Should follow 4th yr TH program (unique
conferences, rotations, etc)
• May need to adjust other rotations for GI
– Golden rule
– One less fellow to do advanced procedures and other
rotations 3rd yr fellows do
• TH PD must coordinate and work with GI PD
– Evaluations, QI Projects, schedule, Milestones

19. What the TH Pilot Fellows should still do
– Fellow should still take GI call
– Fellow continues continuity clinic
• Could be in Hepatology or GI
– Fellow should continue to do endoscopy (~1/2
per week)
– Fellow continues to participate in all GI
educational programs (conferences, etc)
– Must complete the outcomes measures of the
TH Pilot Program
• AASLD TH PD Tool Kit (AASLD.org)

20. What the TH Fellow should NOT do
• Advanced procedures
– ERCP, EUS, DBE, etc
• Function as a third year GI fellow to cover
other GI fellows
• Change GI programs in the third year from
one that does not offer TH to one that
does

21. The Process
• Identify potential TH Pilot Fellow by middle of 2 nd
year of GI training
• Obtain approval from your institution’s GME for
the new “training track”
• TH and GI PD (both sign) and send letter of
intent to the AASLD TH Steering committee
identifying fellow and commitment to TH Pilot
• Once approved, that fellow’s name is sent to
ABIM to allow them to sit for TH Boards after
they pass GI Boards without having to do 4 th yr
• Only limited by number of TH approved slots

22. Summary
• There is a shortage of transplant
hepatologists
• TH Pilot Program will allow selected
fellows to complete their transplant
hepatology training within the 3 years of
GI
• Can only work with cooperation of GI PD
• May be used as a recruiting tool
• We are tracking outcomes of the program