Transplant Hepatology Pilot

Richard K. Sterling, MD, MScProfessor of Medicine

Chief, Section of HepatologyProgram Director, Transplant Hepatology

Virginia Commonwealth UniversityRichmond, VA

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

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

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

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

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

MilestonesDefinition: 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

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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.’’

Ten Cate O. Med Education 2005A Koteish

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

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training deliberate professional practice

proficient

expert

competent

advanced

novice

Competency Curve over time

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Competency Curves for Trainee

Training Deliberate professional practice

EPA1

EPA4

EPA2

EPA3

EPA5

Competence

Threshold

Justified entrustment decisions

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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

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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 STARA Koteish

Transplant Hepatology EPA: K/S/A

Transplant Hepatology EPAs vs. CompetenciesEPAs do not conflict with or replace competencies (or milestones) but rather

complement or are comprised of competencies and milestones.

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Transplant Hepatology EPAs

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 3rd 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)

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

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)

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

The Process

• Identify potential TH Pilot Fellow by middle of 2nd 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 4th yr

• Only limited by number of TH approved slots

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– This is a work in progress