Training the next generation of hepatologist: What will they need to know?

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Abbreviations

AAMC

American Association of Medical Colleges

AASLD

American Association for the Study of Liver Diseases

ABIM

American Board of Internal Medicine

HCC

hepatocellular carcinoma

HCV

hepatitis C virus

NAFLD

nonalcoholic fatty liver disease.

Hepatology has come a long way as a specialty of medicine. When the American Association for the Study of Liver Diseases (AASLD) was founded in 1950 by a handful of like‐minded academics, hepatitis B had yet to be described, and the first liver transplant in humans was still 13 years away. The field has now blossomed into a fertile area for research and patient care; transplantation is now commonplace, viral hepatitis has been described and is increasingly eradicable, and the specialty has its own literature, training, and certification by the American Board of Internal Medicine (ABIM). Despite these successes—and in part due to them—we face significant shortages in the workforce that cares for patients who have chronic liver diseases. Chronic viral hepatitis affects one out of 50 people in the general population, and nonalcoholic steatohepatitis affects one out of every 20 to 30 individuals.1 The passage of the Affordable Care Act in 2012 and other factors has led the American Association of Medical Colleges (AAMC) to predict a shortage of more than 40,000 specialty physicians by 2020 (Table 1).2, 3 With only a thousand or so fully trained hepatologists and the influx of more insured patients in our communities, the shortage of hepatologists is likely to increase. With major changes in health care on the horizon, we must determine what skills hepatologists will need and what new challenges they will be facing.

Table 1.

Projected Supply and Demand of Full‐Time Equivalent Physicians Active in Patient Care After Health Care Reform in the United States (2010–2025)

Year	Physician Supply (All Specialties)	Physician Demand (All Specialties)	Physician Shortage (Non‐Primary Care)
2010	709,700	723,400	4700
2015	735,600	798,500	33,100
2020	759,800	851,300	46,100
2025	785,400	916,000	64,800

Adapted from AAMC Center for Workforce Studies, June 2010 Analysis.

The coming decades will be characterized by a changing demographic of patients and disease processes as well as research priorities that fall under the purview of the hepatologic community. Hepatitis C (HCV) will be eclipsed in its long‐standing status as the leading cause of chronic liver disease, hepatocellular carcinoma (HCC), and liver transplantation in the United States.4, 5 Studies suggest that the availability of these new treatments will transform HCV into a rare disease by 2036.6 Although it is predicted that HCV‐related HCC will peak and then decline after 2020 based on past HCV treatment patterns, this diminution will not translate into a parallel decrease in overall HCC (Fig. 1).7, 8 Liver cancers are projected to surpass breast, prostate, and colorectal cancers to become the third leading causes of cancer‐related death by 2030.9 Nonalcoholic fatty liver disease (NAFLD), paralleling the increasing prevalence of metabolic syndrome in the United States, is likely to emerge as the single most important cause of chronic liver disease, including HCC, over the next several decades.10, 11 The management of NAFLD will be a microcosm of the new paradigms of team practice, requiring the collaborative skills of hepatologists, cardiologists, dieticians, endocrinologists, surgeons, midlevel providers, and other health professionals.

Figure 1.

Incidence of liver cancer deaths. Time trends (1975–2010) of population‐based age‐adjusted incidence and mortality rates are shown for liver and intrahepatic bile duct cancer in the United States. Both sexes and all races are included. Adapted with permission from Hepatology.7 Copyright 2014, Wiley.

With population growth and aging being the greatest drivers for increased health care utilization in the future, all physicians must focus on retooling to provide high‐quality care to patients with complex health needs.12 Hepatologists will be called on to provide leadership in determining allocation of resources due to their experience with costly antiviral pharmaceuticals and liver grafts. Issues in organ allocation have inspired hepatologists to work in multidisciplinary teams, treating critically ill patients in the setting of scarce medical resources.13 These experiences will provide us with further leadership opportunities in such burgeoning areas as universal access to health care, telemedicine, and interprofessional practice.

Liver transplantation has evolved from an experimental procedure in the early 1980s to the most effective treatment for patients with advanced liver cirrhosis and eligible patients with HCC and fulminant hepatic failure. As we progress through the 21st century, the transplant hepatologist will play a crucial clinical role, with essential duties and skills to manage the complexities encountered in patients with acute and chronic liver disease. These skills will include interpretation of noninvasive liver imaging (eg, transient elastography, magnetic resonance elastography), pharmacogenomics, advanced methods for detection and treatment of portal hypertension, and pharmacotherapy for metabolic syndrome leading to NAFLD (Table 2). As these technologies develop, methods to gain competence in them will have to be incorporated into hepatology fellowship training in real‐time to allow for mastery of these skills and seamless application. It is hoped that these advancements will lead not only to increased life expectancy of patients with liver disease but also to increased quality of life.

Table 2.

Important Future Skills of a Hepatologist

Disease State	Skills
Portal hypertension	• Noninvasive monitoring portal pressure
	• Advanced endoscopic treatment for varices
NAFLD	• Noninvasive methods to detect presence of nonalcoholic steatohepatitis
	• Pharmacotherapy for nonalcoholic steatohepatitis
	• Pharmacotherapy for weight loss
	• Effective nutrition counselling
	• Determining genetic risk for progression
Hepatic fibrosis	• Pharmacotherapy for reversal of fibrosis
HCC	• Chemopreventative therapies
	• Early detection and risk identification
	• Molecular profiling for target‐directed therapies
Drug‐induced liver injury	• Individualized pharmacogenomics and metabolomics
	• Advanced methods of liver regeneration and adsorbent recirculating systems
Alcoholic liver disease	• Effective treatments for alcoholic hepatitis
Transplantation	• Induction of operational tolerance
	• Improved management and prevention of metabolic syndrome associated with immosuppressants

The hepatologic research agenda for the coming decades promises to tackle improved treatment of HCC, reversal of hepatic fibrosis, eradication of hepatitis B, more effective treatments for autoimmune liver diseases, and induction of operational tolerance in transplant recipients. A needed increase in the hepatology workforce produced by different fellowship tracks will play a large role in providing these advances to patient (Table 3). Those hepatologists interested in academic medicine with a focus on basic or translational research may opt for the traditional pathway of an additional year of training following certification in gastroenterology. A 3‐year combined Gastroenterology/Transplant Hepatology fellowship track, cosponsored as a 10‐year pilot by the AASLD and the ABIM, has shown early success in applying competency‐based training and assessment, allowing a shorter training time for those fellows wishing to pursue a clinical career. The hepatology community will need to carefully monitor the progress of the 3‐year training pilot to insure the quality of trainees, the effect on workforce needs, and the potential influence on individuals who choose research‐intensive careers.

Table 3.

Training Models in Transplant Hepatology

Four‐Year Program		Three‐Year Combined Gastroenterology/Transplant Hepatology Programa
Training Area	Duration	Training Area	Duration
Gastroenterology	13 months	Gastroenterology	2 years
Hepatology	5 months	Transplant Hepatology	1 year
Research/Electives	18 months
Transplant Hepatology	1 year

^aStill in pilot program phase.

In summary, the hepatology workforce of 2050 will undoubtedly possess an armamentarium capable of treating inflammatory, metabolic, and degenerative diseases of the liver, reversing hepatic fibrosis and managing the complications of advanced liver disease. Hepatology is likely to continue its evolution from the specialty of gastroenterology; board certification will continue to be required after gastroenterology training to ensure attainment of this specialized set of knowledge and skills. More difficult to predict is the direction of the health care delivery system, but it is safe to assume that multispecialty teams, development of chronic care models, and emphasis on value of services will be part of the equation. Ultimately, the future success of hepatology will be based on our ability to continue to sustain innovation in patient care, research, and education so as to improve both the quantity and quality of life for our patients.