Beyond Fellowship….. Seeking Additional Training

1. Beyond Fellowship…..Seeking Additional Training GI Division Rounds Brian Brauer, MD February 14, 2006

2. Who?Should consider advanced training…. • Primarily those with an interest in an academic career when adequate exposure is not received during the standard fellowship program • A few other isolated instances

3. What: • Advanced Endoscopy • Transplant Hepatology • IBD • Motility • Other organ specific programs: esophagus, pancreas, etc. “If there’s an organ, Mayo has a program for it”

4. Things to Consider • How to find programs: Is it a secret? • Funding • Accreditation • Experience • Additional responsibilities • Time commitment • Application timetables

5. Finding Programs • Most societies offer a list of programs that offer advanced training • Most of these include all fellowship programs, not just those providing “third tier” training • Most lists are outdated

6. Finding Programs • Resources: • Faculty in that area • Faculty that trained at highly subspecialized institutions • Other fellows that have applied • Journal classified ads • Web searches (I found some programs on Google™ that weren’t listed elsewhere)

7. Finding programs

8. Funding • These are non-ACGME accredited fellowships: most GME departments don’t fund the position • Many provide no salary • For funded programs, it is important to find out where the funding is derived, and what additional responsibilities are incurred to support the funding (endoscopy, consult services)

9. Accreditation • CAQ: ABIM Certificate of Added Qualification for transplant hepatology, single day examination beginning November 2006 • Other specialties are more subjective and rely on program directors’ determination of competence and procedure experience

10. Experience • Does the program offer training in everything you desire? • Is there adequate procedural experience/ patient exposure? • How much time is spent doing research or non-patient care activities? • Program philosphy: in advanced endoscopy, some are “purists” who don’t believe it is possible to become truly proficient in both ERCP and EUS

11. Additional Responsibilities • Is there significant or unnecessary call? • Are there responsibilities outside your specified area of training (general GI/endoscopy, general medicine responsibilities) • Are these activities required to fund your position?

12. Time Commitment • Weekend/call responsibilities • Work hours • Can you complete the training you want in the allotted amount of time? • If a program focuses on one area, is there the opportunity to learn others-i.e. “If I spend a year learning ERCP, can I stay a 2nd year to learn EUS?” • If there is a research requirement, is there protected time?

13. Application timetables • Think about your ultimate goals when planning research time and projects • You should generally start obtaining information and securing letters 18-24 months before anticipated start date • No uniform application timetable, more competitive programs tend to start earlier • There is no harm in contacting a program early to inquire about their application process, especially in the era of e-mail

14. Endoscopy

15. Endoscopy • Duration: 1 year, may include ERCP, EUS, or both • Aliases: Advanced Endoscopy, Interventional Endoscopy, Therapeutic Endoscopy, Biliary Endoscopy, Pancreaticobiliary Endoscopy

16. What is an “advanced” procedure? • ERCP and all interventions • EUS • Dilation of complicated esophageal strictures • Laparoscopy • Luminal stents • PDT • Laser therapy • Mucosectomy • Endoscopic tumor ablation ASGE, 2006

17. What Constitutes Advanced Training? The American Society for Gastrointestinal Endoscopy (ASGE) has proposed that “more complex diagnostic and therapeutic procedures are used less frequently than standardized procedures and are more likely to have complications. Therefore, their successful performance requires fewer endoscopists with more skill and experience, gathered during a longer training period. It is not possible for all training programs to teach all endoscopic procedures to all fellows, nor is it necessary for optimal patient care. Acquisition of advanced skills by selected fellows seeking such experience usually requires an additional period of training, often for one year after fellowship.” Principles of Training in Gastrointestinal Endoscopy. Manchester, Massachusetts: The American Society for Gastrointestinal Endoscopy, February 1998.

18. ERCP Requirements • ERCP: 180-200 procedures recommended, at least 50% with a therapeutic component (sphincterotomy, stone extraction, lithotripsy, stricture dilation, stent placement, cholagioscopy/pancreatoscopy) • Cases in which native anatomy is altered (prior sphincterotomy, routine stent change) excluded • Cannulation of desired duct with >80% success rate • Jowell et all showed 180 as the minimum for competence, success rate approached 90% with 200+ procedures ASGE 2006 Jowell et al., Ann Int Med 1996

19. ERCP Requirements • Kowalski et al showed in a survey of graduating GI fellows, 69 completed survey, 36% of fellows achieved 80% success rate and appropriate comfort level for performing sphincterotomy, 64% did not achieve competence, 33% reported inadequate ERCP training, yet 91% responded they expected to perform ERCP’s unsupervised following training Kowalski et al., GIE 2003

20. Endoscopic Ultrasound (EUS) • Trainess should be skilled in diagnostic endosonography prior to undertaking interventional aspects of EUS such as FNA • ASGE guidelines are outdated, much has evolved since they were created in 1999 Van Dam J et al. GIE 1999;49:829-33 Faigel D et al. Ensuring Competetency in Endoscopy. ASGE/ACG 2005.

21. EUS Trainee Requirements • 1. Perform EUS based upon findings from a personal consultation/evaluation and considering other diagnostic and therapeutic alternatives available as well as understanding the risks and complications of the procedure. • 2. Perform the procedure in a safe and efficient manner. • 3. Interpret most EUS findings for a variety of indications. • 4. Recognize and manage complications related to the procedure. Van Dam J et al. GIE 1999;49:829-33

22. ERCP Trainee Requirements • Trainees who are seeking to acquire skills in advanced endoscopic training must have completed standard endoscopy training during an approved GI fellowship (or equivalent training) and have documented competence in general routine (i.e., not advanced) endoscopic procedures. • The trainee must devote a substantial portion of his/her advanced endoscopic training to developing skills in the cognitive as well as technical component of procedures, including understanding the appropriate indications for, as well as the contraindications to, performing these procedures. They should be taught to manage patients through all aspects of their endoscopic care with particular emphasis on pre and post procedure evaluation as well as managing procedure-related complications that may occur. The trainee should have the ability to explain the procedure to the patient, including obtaining informed consent. • Trainees are required to maintain a log of all advanced therapeutic procedures performed under supervision to document indications, specific procedure(s) performed and complications to enable them to document comparison of their findings with an objective standard. • Advanced procedure trainees are expected to perform clinical research and/or scholarly activities related to advanced therapeutic endoscopy and develop skills to prepare them to become teachers of endoscopy. ASGE, 2006

23. Advanced Endoscopy Program Requirements • focus clinical responsibilities so as to enable the trainee to develop an approach to the patient requiring therapeutic/interventional endoscopy, understand appropriate indications for advanced procedures, perform pre- and post-endoscopic evaluations, and manage procedure-related complications; • limit outpatient responsibilities (not related to therapeutic endoscopy) to no more than one half-day per week; • minimize time performing “routine” consults; • create an environment with an emphasis on endoscopic research; • provide time and facilities (amounting to at least 30% of effort) for “academic pursuits” (e.g. designing/writing research protocols, attending courses in statistics, epidemiology, study design, writing original papers and reviews under the supervision of senior staff, etc.); • provide advanced trainees with the time and funds to attend at least one scientific meeting per year—preferably one related to therapeutic endoscopy; • provide an exposure to endoscopy unit management (scheduling, staffing, equipment maintenance, management skills, etc.)

24. Where to find programs • EUS programs: http://www.asge.org/pages/education/training/eus.cfm • This is a list of all programs that offer some degree of EUS training, not all are 4th year programs, but does provide a description and funding status • ERCP/combined programs: list available from ASGE but includes all programs, not just 4th year • AGA Program Directors’ website lists some programs that offer advanced endoscopy, but is very outdated

25. Other things to find out: • If a program offers training in both ERCP and EUS, it is important to know if some faculty members do both procedures • Programs in which some faculty do both procedures tend to be more innovative

26. Transplant Hepatology

27. Transplant Hepatology • Usually 1 year • Probably the most recognized sub-subspecialty in GI • ABIM Certificate of Added Qualification slated to begin in November 2006 • In preparation, the American Society for Transplantation and AASLD have recommended a standardized curriculum

28. Training Program Requirements • 1. The transplant program must be United Network for Organ Sharing (UNOS)-approved (or Canadian equivalent), in good standing as a liver transplant program, and be affiliated with an ACGME approved gastroenterology training program. • 2. The transplant program must perform at least 30 liver transplantations per year or 20 transplantations per year for each liver transplant fellow to be trained. • 3. The program must have a full-time faculty member or members capable of teaching a curriculum with a broad base of knowledge in transplant medicine and hepatology. At least one faculty member must be a fully trained hepatologist, defined by the Task Force on Training in Hepatology. Rosen H et al. Liver Transplantation 2002;8:85-7.

29. Training Program Requirements • The medical director of the program must have recognized expertise in liver diseases, including ongoing productivity in clinical or basic research related to liver diseases and transplantation. The program must provide patient comanagement responsibility with transplant surgeons from the preoperative phase to the outpatient period. The program must provide training in the indications for, performance of, and interpretation of liver transplant biopsies. Furthermore, the program must provide didactic experi-ence with the trainee reviewing liver transplant biopsy specimens with an experienced liver transplant pathologist. Rosen H et al. Liver Transplantation 2002;8:85-7.

30. Training Program Requirements • 4. The curriculum designed by the training program director should follow the guidelines summarized next and must include training and experience in end-stage liver disease; training in the selection of appropriate transplantation recipients and donors (cadaveric and living), including ethical issues; understanding of surgical procedures; and experience in the immediate and long-term medical care of the transplant recipient (e.g., recurrent disease). Additionally, there must be an emphasis on the management of immunosuppressive agents (including pharmacokinetics and drug-drug interactions) and evaluation of liver allograft dysfunction. It is strongly recommended that the didactic section of the program follow the AST’s Primer on Transplantation. 5. The program must have a close working affiliation with an interventional radiology program experienced in the broad range of interventions pertinent to the management of hemodynamic, vascular, and biliary problems occurring in end-stage liver disease and transplant recipients. 6. The liver transplant fellowship program must provide training in living donor transplantation. If such training is not available on site, the program must provide the fellow with travel and accommodation to gain this experience. Specifically, a multidisciplinary approach to issues in donor selection and evaluation and recipient criteria in a well established program are recommended. Rosen H et al. Liver Transplantation 2002;8:85-7.

31. Requirements for Trainees • Must meet level 1 and 2 training requirements per AGA core curriculum in Hepatology before or during training period: The minimum requirement for level 2 training includes the preparation of the individual to diagnose and manage all types of liver disease, acquisition of the procedural skills listed below, and proficiency in performing liver consultations. In addition, experience in the evaluation of patients for liver transplantation is essential. It is assumed that to meet these criteria, at least 18 months of training will be devoted to training in hepatology. This could be completed during the 3-year fellowship in gastroenterology or necessitate a fourth year of training devoted to hepatology. Two of the months must be spent on a liver transplant service. Rosen H et al. Liver Transplantation 2002;8:85-7. AGA Core Curriculum, 1996.

32. Requirements for Trainees(In addition to meeting level 1 & 2 training requirements) • 1. The trainee must have at least 1 year of specialized training in liver transplantation under the direct supervision of a qualified (UNOS-certified) transplant hepatologist and in conjunction with a liver transplant surgeon at a UNOS-approved (or Canadian equivalent) liver transplant center. The 12 months of training would preferably be contiguous, but must consist of a minimum of 4 months on the clinical inpatient adult liver transplant service, with weekly continuity clinic for the 12 months. The remaining months should consist of other hepatology or transplant-related experience, including involvement in basic or clinical transplant research.

33. Requirements for Trainees • 2. The trainee must be thoroughly acquainted in principle and practice with the management of patients with acute and chronic end-stage liver disease.This will include the following criteria: (a)Experience in the comprehensive management of patients at high listing status in the intensive care setting, with complications including refractory ascites and hepatic hydrothorax, hepatorenal syndrome, hepatopulmonary and portopulmonary syndromes, and refractory portal hypertensive bleeding. A detailed familiarity with the principles and application of transjugular intrahepatic portosystemic shunts is essential. (b) The diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma, including transplantation, nontransplantation surgical, and nonsurgical approaches. (c) The management of chronic viral hepatitis in the pretransplantation, peritransplantation, and posttransplantation settings. (d) The management of fulminant liver failure, including principles of intracranial pressure monitoring. (e) The psychosocial evaluation of all candidates, in particular, those with a history of substance abuse. (f ) A working knowledge of transplant immunology, including blood group matching, histocompatibility and tissue typing, and infectious and malignant complications of immunosuppression. (g) Drug hepatotoxicity and the interaction of drugs and the liver. (h) Nutritional support of patients with chronic liver disease. (i) Use of interventional radiology in the diagnosis and management of portal hypertension, as well as biliary and vascular complications. (j) Ethical considerations relating to liver transplant donors, including questions related to living donors, non–heart-beating donors, criteria for brain death, and appropriate recipients.

34. Requirements for Trainees • 3. The trainee must be involved in the primary evaluation, presentation, and discussion at selection conferences of 20 or more potential transplant candidates. • 4. The trainee must follow up at least 20 new liver transplant recipients for a minimum of 3 months from the time of their transplantation. The trainee will be directly supervised in the evaluation and management of patients from the preoperative to outpatient period. The liver transplantation trainee must actively participate in transplant recipients’ medical care, including acute cellular rejection, recurrent disease, infectious diseases, and biliary tract complications. Furthermore, the trainee must serve as a primary member of the transplantation team and participate in making decisions about immunosuppression.

35. Requirements for Trainees • 5. The trainee must be involved in the follow-up of 30 or more liver transplant recipients who have survived more than 1 year after liver transplantation to gain familiarity and expertise with the management of common long-term problems (e.g., cardiovascular disease, nephrotoxicity, screening for malignancies, and diagnosis and treatment of recurrent disease). • 6. The trainee must understand the indications, contraindications, complications, and interpretation of allograft biopsies and must perform a minimum of 30 percutaneous biopsies during the training period. The trainee also should be familiar with the appropriate use of ultrasound-localized and laparoscopy-guided liver biopsies. • 7. The trainee must acquire a current working knowledge of the organizational and logistical aspects of liver transplantation, including the training and role of nurse coordinators and other support staff (e.g., social work), organ procurement, and UNOS policies.

36. Requirements for Trainees 8. The trainee must participate as an observer in three cadaveric liver procurements and three liver transplantations. The trainee is expected to learn the principles of donor selection and rejection (e.g.,hemodynamic management, donor organ steatosis, and indication for liver biopsy). 9. The trainee should be exposed to the evaluation of at least five adult-to-adult living donor liver transplantations, even though this procedure is not available in the current training program (see training program requirements). During this experience, the trainee must become familiar with the principles of living donor selection, including appropriate surgical, psychosocial, and ethical considerations. 10. The trainee must become familiar with the following factors: (a) principles and practice of pediatric liver transplantation, (b) principles and application of artificial liver support, and (c) clinical research issues in transplant hepatology. Rosen H et al. Liver Transplantation 2002;8:85-7.

37. Where to Find Programs • AASLD provides a list of programs, this list includes all liver transplant programs • https://www.aasld.org/eweb/DynamicPage.aspx?Site=AASLD3&WebKey=f4c4c8ab-0ed2-4d70-9ab2-c03458f668a9 • Does give listing of volume and fellowship slots

38. Other Resources

39. Inflammatory Bowel Disease

40. Inflammatory Bowel Disease • Duration: 1-2 years depending on research requirement • Less structured and regulated than other advanced training programs

41. Core Curriculum Guidelines • Training Process: Unlike many other consultative aspects of gastroenterology, the trainee should be able to assume responsibility for both inpatients and outpatients with IBD and related disorders, encompassing their diagnoses, acute and chronic therapies, long-term follow-up, and counseling of the families and/or significant others. Adequate experience should include exposure to hospitalized as well as ambulatory patients as well as the initial assessment and longitudinal management of patients with IBD, particularly in the ambulatory setting, under the supervision of a skilled attending physician. AGA Core Curriculum, 1996.

42. Core Curriculum Guidelines • Assessment of Competence: Knowledge of the gastrointestinal inflammation curriculum should be assessed as part of the overall evaluation of the trainee in gastroenterology during and after the fellowship, as outlined by the Task Force on Overview of Training in Gastroenterology. No specific examination or other instrument of assessment need be developed for this portion of the training. AGA Core Curriculum, 1996.

43. Help is on the way….

44. Other Subspecialties

45. Other Programs • Motility • Other organ-specific subspecialties • Usually one year or less • No standardized training guidelines, but recommended minimal experience for interpretation of motility studies exist • Many of these such programs are “unofficial” or “informal” fellowships consisting of a few months training

46. Motility AGA Core Curriculum

47. Where to Find Programs • Mainly word of mouth: ask the experts in the area of interest

48. Summary • There is wide variation in structure and and philosophy or advanced training programs • Start early if you’re interested • Ask around, get the “inside scoop” • Determine your career goals prior to applying, this may ultimately help with funding • Select a program that will provide the training you want; don’t go to a program expecting training in an area it doesn’t claim to provide