A call to action: The need for hepatology‐focused educational interventions in Internal Medicine Residency training

Field: Health Professions (Health Sciences)

Potential conflict of interest: Nothing to report. To the Editor: The prevalence of chronic liver disease (CLD) is steadily increasing in the United States. Despite increasing disease burdens, there is a significant shortage of hepatologists (∼1800) in practice.1 This stark imbalance highlights the critical need for Internal Medicine (IM) physicians to competently care for CLD patients. The IM Residency Program at the University of Chicago, which historically has only offered elective consult rotations in gastroenterology and hepatology, sought to assess its graduating postgraduate year‐3 (PGY‐3) IM residents' knowledge of and comfort with the management of CLD. A paper‐based anonymous survey was distributed to 27 PGY‐3 IM residents. The assessment included 12 standardized multiple‐choice questions from the Medical Knowledge Self‐Assessment Program 15 and the Digestive Diseases Self‐Education Program and 25 items which assessed self‐efficacy and preparedness to manage CLD using Likert scales. Additionally, deidentified American College of Physicians IM In‐Training Examination data from 2011 to 2013 were analyzed. The residents overwhelmingly agreed that gastroenterology and hepatology were integral to IM training; however, despite seven opportunities to do so, 44.4% did not elect to rotate on either of these consult services during residency. All of the PGY‐3 residents agreed that they were comfortable managing certain common general medicine and cardiology conditions (Fig. 1A). However, only a minority were comfortable managing common hepatologic diseases (e.g., hepatitis B and C, nonalcoholic steatohepatitis, cirrhosis, hepatorenal syndrome, and acute liver failure). Interestingly, they were more comfortable with topics that frequently overlap with other IM rotations (e.g., spontaneous bacterial peritonitis, performing a paracentesis, and abnormal liver function tests).Figure 1: (A) The percentage of residents who were comfortable managing each topic surveyed. (B) The percentage of residents who answered each hepatology‐related question correctly. Abbreviations: LFT, liver function test; HCV, hepatitis C virus.Overall, the residents performed poorly on the objective assessment of CLD knowledge; the mean percentage of correct answers was only 56.5% (Fig. 1B). Only 37% of the residents elected to rotate on the hepatology consult service during their residency; these individuals scored slightly higher (60%) than those who did not (54.4%). Furthermore, the mean percentage of hepatology questions answered correctly on the In‐Training Examination by the resident cohort of this study was 71% in PGY‐1, which downtrended to 63% in PGY‐3. A similar trend was observed nationally as well. These data strikingly demonstrate that many graduating PGY‐3 residents do not have a strong understanding of CLD and that postgraduate hepatology‐focused educational interventions are needed. Furthermore, despite overwhelming agreement that the gastroenterology and hepatology services are integral components of IM, many have never rotated on either. This suggests that the traditional learner‐centric system, which allows trainees to electively choose specialty rotations, may be contributing to inadequate education in specialty topics, including hepatology. In response to these data, our IM Residency Program has established a nonelective liver rotation that 26 categorical residents will rotate on each year. The educational strategies employed on this service, including mandated modules in the ACT‐First Hepatitis B and C curriculums in LiverLearning of the American Association for the Study of Liver Diseases, are now being studied to assess for improved understanding of CLD among residents.