For: Joint Committee for Higher Medical Training
The aim of this document is to justify the need for recognition of Hepatology as a sub-speciality of Gastroenterology with specific training requirements. It has been prepared by the Secretary and President of the British Association of the Study of the Liver (BASL) and the Chairman of the SAC in Gastroenterology at the request of the newly established Joint Speciality Committee for Gastroenterology & Hepatology of the Royal College of Physicians. This request was in response to a growing concern that the current Specialist Registrar (SpR) Training programme in Gastroenterology provides insufficient training for physicians planning a career predominantly in liver medicine at a time when the demand for liver-trained physicians is increasing. A shortage of trained liver transplant physicians is viewed as a particular shortfall of the current training programme. The increasing burden of liver disease in the UK has recently led to moves towards establishing designated Liver Units in all health regions, and to a growing trend for larger District Hospitals with teams of three or four gastroenterologists to have one of these trained in liver disease. A formalised programme of Hepatology training can be justified in terms of: (a) the increasing complexity of managing complicated liver problems; (b) the economic implications of some newer treatment regimes; (c) the need to train physicians in transplant hepatology and in the management of rare liver conditions; (d) the need to foster clinically driven hepatological research. The implications of recognising Hepatology as a sub-speciality within Gastroenterology, including modifications to the current Gastroenterology SpR Training Scheme and definition of appropriate training programmes are outlined.
Recommendations:
1. Hepatology to be recognised as a sub-specialty normally entered by CCST- accredited gastroenterologists.
2. Approximately 14 (fourteen) new posts to be created to enable SpRs accredited in Gastroenterology to spend a sixth year training in the sub-speciality of hepatology
3. Sub-speciality accreditation will only be available to SpRs who have spent, in total, a minimum of two years training in designated Liver Units, 18 months of which should be spent in clinical posts.
4. A minimum of six months of the 2 years will be spent training in a designated Liver Unit with an active liver transplant programme and at least six months should also be spent in a designated Liver Unit with no transplant programme.
5. As for other trainees in Gastroenterology, trainees in hepatology will be expected to be trained in diagnostic and therapeutic endoscopy to JAG standards.
It has become increasingly clear to hepatologists working in established Liver Units that the current SpR training programme in Gastroenterology provides insufficient training for those few physicians planning a career predominantly in liver medicine. Spending one year of a 5 year SpR training programme in a “liver post” is clearly insufficient. Eminent leaders of the profession have expressed a deep concern regarding the lack of any training provision from which the next generation of hepatologists/liver transplant physicians could be anticipated to emerge. At present, for example, the 3 physicians appointed to consultant posts advertised as requiring special experience/expertise in Hepatology in England in the past 6 months had all received much of their training in Hepatology as clinical research fellows on UK Liver Transplant Units rather than within a formal SpR training programme. There were only two applicants for each of these posts as against 10 or more for conventional consultant Gastroenterologist posts – almost certainly reflecting the paucity of adequately trained clinical hepatologists in the UK.
These concerns have recently led to the suggestion that Hepatology should be established as a sub-speciality of Gastroenterology. It is emphasised that this is not a proposal for a “new” speciality within the JCHMT, rather, physicians specialising in Hepatology would follow a modified programme with some different educational goals. This would be similar to the model currently being worked on for metabolic medicine where it is anticipated that, in future, both endocrinologists and clinical chemists might be accredited in their speciality “with metabolic medicine”. Although there are already de facto Liver Units in most regions the demand for liver-trained physicians seems likely to expand. First, there have been recent moves, initiated by the Department of Health, for Hepatology Services to be commissioned on a Regional basis implying the development of designated Liver Units. Clearly, there is little point setting up these units if there is no way of determining which clinicians are suitably qualified to run them. Secondly, in most larger districts with teams of 3 or 4 Gastroenterologists, it is seen as increasingly desirable that one of these should have received specialist training in liver disease. Against this likely background scenario it is proposed that approximately 20-25% of SpRs in Gastroenterology will proceed to acquire further accreditation in the sub-speciality of Hepatology . Importantly, the establishment of a sub-speciality of Hepatology is not intended to replace or disadvantage the general hepatology training of the ordinary Gastroenterology Trainee.
1. The burden of liver disease
Liver disease represents a considerable burden to the National Health Service. A 1998 audit showed that in Newcastle alone (a Regional Liver Unit), 787 patients were admitted with liver-related problems, alcohol-related disease accounting for 38% of these cases. The sero-prevalence of Hepatitis C virus in the United Kingdom has been estimated at between 0.2-1%, with approximately 20% of these cases progressing, untreated, to chronic liver disease and hepatocellular cancer. Indirect evidence has recently suggested that so-called non-alcoholic fatty liver disease (NAFLD), associated with an “affluent society”, may be present in up to 2% of the US population and may progress to cirrhosis in up to 30% of cases. Moreover, the UK death rate from cirrhosis almost doubled between 1987 and 1997. It is unreasonable to expect this increasing disease burden with its serious complications to be managed by clinicians trained predominantly in Gastroenterology with patchy or absent specialist training in hepatology.
In no way is it envisaged that management of all liver “problems” will be undertaken solely by individuals gaining certification in Hepatology or exclusively on designated Liver Units. For this reason, it is recognised that it remains essential for all SpRs planning a career in “main-stream” Gastroenterology to receive some training in Hepatology. Hepatology should remain an important component of training for all gastroenterologists and this proposal is not meant to diminish the existing training opportunities in the discipline of hepatology for all trainees in Gastroenterology. The current 6 months in the Gastro SpR programme would appear to be sufficient for this purpose. It is felt, however, that the majority of gastroenterologists referring patients to designated Liver Units for a ‘Liver Opinion’, would expect the Physician to whom they are referring to have received more training than themselves in Hepatology. This is only true at present because most Physicians working on Liver Units have spent time doing research on such units and have acquired hepatology experience in an unstructured way. This largely informal way of training future hepatologists working in either designated Liver Units or District Hospitals clearly cannot be allowed to persist in the current climate of clinical governance.
2. Issues of patient management.
a. Management of complicated liver problems. Recent advances in the investigation and management of portal hypertension (Transjugular Intrahepatic Portosystemic Shunts [TIPS]), hepatorenal syndrome and hepatobiliary malignancy, to give just a few examples, have led to the development of multidisciplinary “Liver Teams” consisting of hepatologists, hepato-biliary surgeons, specialised liver radiologists and liver pathologists concentrated largely in major Liver Units. The demands of clinical governance are increasingly concentrating major hepatobiliary and pancreatic surgery in a few centres where the large volume of work and regular audit achieve the best clinical results. Opportunities for training in this multidisciplinary approach to complicated liver problems are clearly available only in these centres. It is essential that SpRs sub-specialising in hepatology receive training in this highly specialised environment.
b. Liver transplantation. Liver transplantation can be viewed as a special solution to a number of complicated liver problems. It is important that some SpRs are trained in the specialised management of patients undergoing liver transplantation. Equally, it is inappropriate for SpRs intending to concentrate largely on Gastroenterology to receive all their hepatology experience solely in liver transplantation. The recognition of hepatology as a distinct sub-speciality with specific training requirements would again allow training in transplantation to be appropriately targeted at Hepatology Trainees. Some of these trainees will eventually become physicians in liver disease in non-transplant centres where their expertise will complement the gastroenterological interests of their colleagues and ensure that the pattern and timing of referral to designated Liver Units and transplant units is optimal.
c. Acute liver failure. Perhaps the best example of a condition fulfilling both the above criteria is acute liver failure (ALF) – a “complicated liver problem” which, in view of frequent need for transplantation is managed almost exclusively on Liver Units with a transplant programme. Patients with ALF present a largely unique constellation of clinical problems requiring the input of an experienced multi-disciplinary team including hepatologists, transplant surgeons, anaesthetists, intensivists and nephrologists. Training in the acute management of these patients is only available on designated liver transplant units. SpR’s trained in the management of these patients will gain valuable experience in the treatment of a variety of “acute” hepatic problems (eg. encephalopathy) and become familiar with the indications for transferring patients with liver failure to a transplant unit.
d. Viral hepatitis. The prevalence of chronic hepatitis C in the UK is between 0.2 and 1%. The management of this enormous group of patients is not straightforward. Not all infected individuals are suitable for/require treatment, some require different treatment duration and in some, close monitoring of their response to treatment can lead to early drug withdrawal in unresponsive patients. It is vital that a significant proportion of gastroenterologists are trained in the management of this large patient cohort and this can best be achieved by recognition of hepatology as a sub-speciality of Gastroenterology with specialised training targeted specifically at Hepatology trainees.
e. Rare conditions. Many forms of chronic liver disease occur relatively infrequently in the community, for example Wilson’s disease, a1- antitrypsin deficiency and haemochromatosis. Recent advances in molecular diagnosis and genetic screening and the subtleties of recognising and managing these rare conditions requires specialist training and considerable experience which cannot be expected to be gained as part of the current 5 year Gastroenterology SpR Training Schemes. The consequences of misdiagnosis and mismanagement of Wilson’s disease at presentation are frequently catastrophic. To train a generation of young consultant gastroenterologists lacking peer expertise in this special discipline would, in our view, be negligent.
3. Economic considerations
Many of the new treatments for liver disease are extremely expensive. Perhaps the best example being the treatments for viral hepatitis. A year’s cost of the anti-hepatitis B virus treatment, Lamivudine, is approximately £800, while a one year course of the currently recommended treatment for HCV (combination therapy with Interferon and Ribavirin) costs around £10,000. For a health region of 3-5 million people this equates to a drug budget for anti-viral treatment alone of £3-5 million per year. Selection of patients is critical (see 2d above) and will be most equitable and cost-efficient if all persons with access to prescribing are selecting from a large patient base, as would exist at designated Liver Units. Clearly these decisions have enormous economic implications and it would seem important that a proportion of trainee gastroenterologists are properly trained in the specialised management of these “expensive” patients.
4. Audit and Research
It is vital that clinicians continue to collaborate closely with basic scientists and statisticians to research into the causes and treatment of liver disease. This includes not only the development of new treatments, but also careful audit of current management strategies. This latter aspect is particularly important in areas with significant cost implications such as anti-viral treatment and transplantation. SpRs receiving extended training in designated Liver Units would be actively encouraged to undertake a period of relevant liver-related research and thus become better equipped for this purpose
5. Government and public perception
Formal recognition of hepatology as a sub-speciality will play an important role in raising the profile of liver disease in the eye of both the public and the government. For the public this is very relevant for issues of health education, such as alcohol (an NHS priority area) and hepatitis C, as well as for fund-raising for research support – currently a huge problem for the British Liver Trust. As for the government, in 1998 the NHS Executive circulated a consultation document concerning the commissioning process of specialised services. Despite the large and increasing burden of liver disease to the NHS, hepatology was not included in the original list of services. (This has now been rectified).
Implications of recognising hepatology as a speciality within gastroenterology.
The major implications/area for discussion inherent in establishing Hepatology as a sub-speciality of Gastroenterology would include:
1. Modifying/extending the Gastroenterology SpR scheme.
Hepatologists-in-training should spend at least 2 years of their SpR programme on a designated Liver Unit. While one of these years could be included in the current 5-year minimum training programme (for Gastro/G(I)M), the other would involve an extension of the scheme to 6 years (see suggested products training Table below). At least 6 months of the 2 years hepatology training should be spent on a designated liver unit with an active transplant programme and a further 6 months should be spent on a designated liver unit without an active transplant programme. It is accepted that those hepatologists planning to work on Liver Transplant Units would normally spend most of their 2 years training on these units. At least 18 months of the 2 year hepatology training must be spent in clinical posts.
|
Year 1 |
Year 2 |
Year 3 |
Year 4 |
Year 5 |
Year 6 |
Output |
5 year |
GIM/GI |
GI |
GI/HEP |
GI/GIM |
GIM/GI |
- |
GI/GIM |
6 year |
GIM/GI |
GI |
HEP |
GI/GIM |
GIM/GI |
HEP |
GI+HEP/GIM |
2. Definition of an appropriate training programme.
The purpose of the training programme will be that trainees should be suitable for appointment as a Consultant Hepatologist providing a high quality service for tertiary referrals from consultant gastroenterologists at a regional or tertiary designated Liver Unit. The curriculum (attached appendix) in advanced hepatology complements the training in general hepatology included in the curriculum for all Gastroenterology Trainees. It is not envisaged that training in ERCP will be a required component of hepatology training. However, since ERCP is an important requirement in liver units, trainees may consider adopting the ERCP option during their general Gastroenterology training.
3. Recognition of trainers and units suitable for training.
Centres providing appropriate experience for advanced hepatology training will apply to the SAC for approval, which will be decided after consultation with BASL. It is anticipated that some training programmes will involve more than one unit – possibly a transplant and a non-transplant unit.
4. Appointment to sixth year hepatology training posts.
These posts will be advertised nationally and will be open to all existing trainees in Gastroenterology who would normally apply for a post in open competition at the beginning of their penultimate year’s training in Gastroenterology/GIM .
5. Manpower decisions.
In addition to the current de facto Liver Units, all of which require fully trained hepatologists, it is anticipated that all large DGH’s staffed by 3-4 gastroenterologists will require one of these to be accredited in the sub-specialty of hepatology. Thus, it is proposed that approximately 25% of SpRs in Gastroenterology will proceed to acquire further training in hepatology . This will require the creation of fourteen new posts. (Calculation based on circa. 420 SpRs in Gastroenterology, currently taking on average 7.2 years from entry to accreditation, circa. 25% becoming sub-specialised ).
1. Obtain appropriate number of NTNs via NHS Executive
