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FAQ: GI-Transplant Hepatology Pilot Fellowship Training

For individual fellows, a benefit is the use of a competency-based model to reduce training time required to become certified in both GI 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 GI 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 American Association for the Study of Liver Diseases (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 GI and transplant hepatology certifications. Most importantly, employers, patients and society will benefit from a group of providers who have demonstrated competence in GI and transplant hepatology through a rigorous training program utilizing innovative assessment methods and established competency standards.

The pilot functions via ABIM-granted individual exceptions to training and therefore does not require IM RRC approval.

Yes. ABIM has approved three competency-based medical education pilots including GI/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.

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.

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, preempt problems and enhance problem solving of such issues across programs. In particular, funding for the pilot fellow is program-specific and may be part of the complement of GI fellows or through other mechanisms. Many GI programs are finding that the pilot is a desired option for many applicants and can be used as a recruiting tool for highly qualified applicants interested in a career in transplant hepatology. Going forward the experience/data gathered from the leading pilot programs will constitute the threshold on which joining programs may build and benefit from, to better plan for and execute the pilot year.

Yes. Candidates will be informed by the 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.

The pilot fellow will be eligible to sit for both specialty certification examinations after completing the three-year pilot (third year of GI). As per current requirements, the fellow cannot register for the transplant hepatology exam until passing the GI 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.

This may be an institution-specific issue, but our advice is to involve the GME office, since the pilot can be seen as a new training track within GI.

No, unless your institution applies for accreditation for a transplant hepatology fellowship program through ACGME.

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.

Inform your GI fellowship program director as early as possible of your interest. You and your program director will be responsible for insuring that most clinical GI requirements are completed by the end of the second year and that the you are on a trajectory to achieve competence in GI by the end of the third year, taking into account that the third year will be focused on development of competence in transplant hepatology. In practice, this means that most, if not all, clinical GI 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 GI fellowship before beginning the pilot year? below.)

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 competetive process; all fellows who meet the criteria will be approved.

No. The criteria for entry into the pilot include a determination by the GI Clinical Competency Committee that the fellow is on a trajectory to achieve competence in GI by the end of the third year. This generally cannot be determined prior to the start of GI 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 GI 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.

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.

No, currently this award is for funding for fellows during a traditional “4th year” transplant hepatology fellowship following three years of GI fellowship.

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.

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 GI fellowship program and an ACGME-approved transplant hepatology fellowship program is eligible to participate. Check with individual GI or transplant hepatology fellowship programs directly to find out if they are offering this pilot pathway
as an option.

Virginia Commonwealth University, Richmond, Virgina
Johns Hopkins, Baltimore, Maryland
Mount Sinai Medical Center, New York, New York
University of Pittsburgh, Pittsburgh, Pennsylvania

University of Wisconsin, Madison, Wisconsin
University Hospitals/Case Medical Center, Cleveland, Ohio
Thomas Jefferson University, Philadelphia, Pennsylvania

Beth Israel Deaconess Medical Center, Boston, Massachusetts
University of California, San Francisco, California
Jackson Memorial Hospital/University of Miami, Miami, Florida
University of Cincinnati Medical Center, Cincinnati, Ohio
Mt Sinai Medical Center, New York, New York
University of California, San Diego, California
University of Florida, Gainseville, Florida
University Hospitals/Case Medical Center, Cleveland, Ohio
Virginia Commonwealth University, Richmond, Virginia
Thomas Jefferson University, Philadelphia, Pennsylvania

Mount Sinai Medical Center, New York, New York
University of Chicago, Chicago, Illinois
University of California, San Francisco, California
University of Minnesota, Minneapolis, Minnesota
Cleveland Clinic, Cleveland, Ohio
Johns Hopkins, Baltimore, Maryland
Emory University, Atlanta, Georgia
Columbia, New York, New York
Georgetown, Washington, D.C.
Duke, Durham, North Carolina

The transplant hepatology program director 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 Taskforce will also request permission to contact the pilot fellow’s chief/supervisor following graduation for a assessment/feedback after the pilot fellow has been in practice for at least one year.

We support the experience of the pilot fellow to ensure continued exposure to GI so that the fellow can continue to work toward achieving competence in GI and to facilitate passing the ABIM certification examination. These activities may include attendance and participation at GI conferences, participation in GI continuity clinic and GI call.

No. The required attendance at conferences should not increase, but should be blended to reflect the required exposure to each specialty.

The pilot fellow should not participate in therapeutic endoscopy procedures or consultations and should not act as “chief GI fellow” during 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 to three months of general hepatology clinical training before entering the third year.

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 GI 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 GI 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 included in the ACGME Subspecialty Reporting Milestones as a distinct subcompetency for all internal medicine subspecialties.

No. (See What about scholarly activity?)

The pilot program is in the “testing phase,” and is not currently replacing the fourth year. The pilot was not designed to replace the fourth year track and may continue to co-exist in programs that have the capacity to train two or more transplant hepatology fellows per year.

ACGME will only require a single set of Reporting Milestones for the pilot fellow, which should be completed by the transplant hepatology program director. This is a change from prior years. The Reporting Milestones should be completed with substantial input from the GI program director and the GI CCC, reflecting the competence of the pilot fellow in GI milestones during the third year.

“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.

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 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 the Mini-CEX be administered at least quarterly.

We are on track to offer the first training exam to pilot and traditional transplant hepatology fellows in the spring of 2016. The exam will be free of charge due to the generous support of the AASLD.

ABIM Practice Improvement Modules® (PIMs) were web-based tools that guided physicians through a review of patient data and supported the implementation of and/or reporting on a quality improvement (QI) plan for their practice. The hepatitis C virus (HCV) PIM was initially 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 and is provided as a document in the required assessment tools for the pilot program but is no longer available online by ABIM.

Not anymore. The Pilot Steering Taskforce recognizes there are many ways that a pilot fellow can demonstrate competence in practice assessment and will now accept completion of an appropriate practice assessment or quality improvement project during the pilot year. The HCV PIM is currently only one option among many.

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.

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.

This is up to the individual program, but we recommend two certificates reflecting the achievement of competence in two distinct specialties, GI and transplant hepatology.

Oren Fix, MD, MSc, FACP (chair)
Swedish Medical Center, Seattle, Washington

Steven Herrine, MD
Thomas Jefferson University, Philadelphia, Pennsylvania

Ayman Koteish, MD
Florida Hospital Transplant Institute, Orlando, Florida

Gautham Reddy, MD
University of Chicago, Chicago, Illinois

Mark Russo, MD, MPH
Carolinas Medical Center, Charlotte, North Carolina

Richard Sterling, MD, MSc, FAASLD
Virginia Commonwealth University, Richmond, Virginia

Talk to your transplant hepatology program director, go to the AASLD website or contact Oren Fix at [email protected].