Why Pursue a Fourth Year in Advanced/Transplant Hepatology?

The traditional pathway for advanced/transplant hepatology training consists of a 1-year fellowship program, accredited by the Accreditation Council for Graduate Medical Education (ACGME), and is usually completed after finishing a 3-year gastroenterology fellowship—thus referred to as a ‘‘fourth year.’’ However, in hopes to increase the number of trained transplant hepatologists given the growing job demand, the American Board of Internal Medicine (ABIM) and American Association for the Study of Liver Diseases (AASLD) have developed a collaborative pilot program, which combines training in gastroenterology and advanced/transplant hepatology within a 3-year timeline at selected institutions [1]. So far, 31 fellows (14 fellows for the current academic year 2015–2016) have enrolled in the program. Interval data evaluating the early metrics of the pilot program are not yet available. This article will focus on the potential strengths in pursuing a fourth year of training in advanced/transplant hepatology as well as the potential pitfalls of the combined pilot program. In the last few decades, immense strides have been made in the discovery, diagnosis, prevention, and management of liver diseases. The incipient field of hepatology continues to evolve with the discovery of novel pathophysiologic mechanisms, drugs, therapeutic modalities, and diagnostic approaches. In spite of this brisk progress, mortality rates from chronic liver disease and liver cancer have increased substantially over the past three decades [2]. Liver cancer is the seventh largest contributor of cancer mortality in the USA [3]. Even with the availability of highly effective hepatitis C virus (HCV) therapies, it is estimated that 300,000 persons will die of HCV in the next three decades [4]. Nonalcoholic fatty liver disease (NAFLD) is estimated to affect 10–46 % of the American population, and the morbidity and mortality associated with NAFLD continue to rise [5, 6]. Although nearly six thousand people underwent liver transplantation in 2015, nearly 15,000 remain actively listed for liver transplantation today [7]. In the foreseeable future, the practice of hepatology will evolve and become more complex with increased applications of personalized medicine as seen with the use of genomics in management of hepatocellular carcinoma. Thus, with rapid expansion of medical knowledge in the field of hepatology and due to the substantial disease burden from liver diseases, there remains great demand for dedicated professional expertise in hepatology. Yet, there is a shortage of providers to fulfill this need and groups have attempted to create pathways in hope to increase the number of such providers. A search on a popular employment search website, www.indeed.com, shows at least twenty current listings for hepatologists across the country (date of search: February 5, 2016). The three-year ABIM pilot training program in gastroenterology and advanced/transplant hepatology was instituted to address the shortage of trained clinical hepatologists in the coming years. However, the ‘‘fourth year’’ still remains relevant, especially for the training of future physician–scientists, whether in basic or clinical research, as this next generation will be instrumental in the continued advancement in the field of hepatology. The traditional training pathway in advanced/transplant hepatology provides opportunity for meaningful research and career development with the provision of dedicated research time during the first 3 years of gastroenterology & Brett E. Fortune brett.fortune@yale.edu