Ball three, strike two: Canadian hepatology at full count

For readers unfamiliar with the game of baseball, ‘balls’ are good and ‘strikes’ are bad. Specifically, balls represent a step forward towards success while strikes represent a step towards failure. A ‘full count’ is when the batter has three balls and two strikes. If the next pitch is a ball (ie four balls), the batter proceeds to first base and is deemed to have had a successful ‘at bat.’ If the next pitch is a strike (ie, third strike), the batter is ‘out,’ and the opportunity to be successful has been lost. In the author’s opinion, Canadian hepatology is at a full count and awaiting the next pitch. But, before we describe how we got there, it would be appropriate to relate how we became a player.

The origins of Canadian hepatology

From the author’s perspective, Canadian hepatology was born in Calgary, Alberta, Canada. That may come as quite a surprise to those who remember the likes of Woody Fisher, Jenny Heathcote, Laurie Blendis, Victor Feinman, and Khursheed Jeejeebhoy from Toronto or Carl Goresky, Pierre Michel Huet, and Claude Roy from Montreal. Indeed, these were extremely knowledgeable clinician-scientists who were considered global opinion leaders in hepatology during the 1960s and 1970s. However, it is important to note that each was a gastroenterologist with an interest in liver disease (G-WILD), and as G-WILDs they were compelled to squeeze hepatology into whatever free time their gastroenterology (GI) practices allowed. Thus, it was not surprising that on the author’s return from training in hepatology at the National Institutes of Health in Bethesda, Maryland in 1982, Toronto, Montreal, and other major centres in the country were very welcoming and provided attractive employment opportunities but only within the context of practising as a G-WILD. The explanation given was there were insufficient numbers of liver disease patients to support a ‘pure’ hepatology practice profile. The sole exception to this mindset was the University of Calgary. There, under the prescient leadership of Eldon Shaffer, the first Canadian full-time hepatologist was hired and the first administratively independent Section of Hepatology was created. Now back to the game.

Ball one: Establishing the Canadian Association for the Study of the Liver (CASL)

Canadian hepatology acquired its first ‘ball’ (ie, took its first positive step forward) in the early 1980s with the formation of CASL. The events leading towards its formation were documented by Dr Jerry Simon in 2012 and are well worth reading (1). Although the author’s recollection was somewhat different from that described, it was not contradictory in that it merely reflects a different perspective. According to the author’s memory, Lloyd Sutherland, a G-WILD in Calgary was responsible for selecting liver disease topics for the Canadian Liver Club’s annual dinner/seminar which was held in conjunction with the American Association for the Study of Liver Diseases (AASLD) meetings each year in Chicago. Having considered (and promptly dismissed) the various options including yet another review of the newly recognized non-A, non-B hepatitis (subsequently known as hepatitis C) Dr Sutherland asked his Calgary colleagues for additional suggestions. The author’s response was, ‘I think the time has come to discuss whether Canada should create its own version of AASLD.’ Dr Sutherland agreed, and the subsequent events were as described in Dr Simon’s paper.

Ball two: Independent CASL annual meetings

Until the early 2000s, CASL annual meetings were integrated into the much larger Canadian Association of Gastroenterology (CAG) Digestive Diseases Week. However, in this format liver papers and awards were allocated to the end of long days, weekends and/or the last day of the CAG meeting. Moreover, in return for the ‘privilege’ of having a presence at CAG days, CASL was deemed responsible for 50% of all deficits related to the meeting but none or a very limited share of the profits. When nAnB (hepatitis C) emerged, the equation changed. There were now two large biopharmaceutical companies with a therapeutic interest in the condition (Schering and Roche Canada) and both saw the need/value of generating strong ties to the Canadian hepatology community. Thus, suddenly the support required for CASL to establish its own stand-alone annual meeting was in place and under the extremely effective and efficient leadership of then CASL President Dr Morris Sherman, the first such meeting took place in Banff, Alberta in 2005.

Ball three: Royal College recognition

In 2013 the Royal College of Physicians and Surgeons of Canada (RCPSC) identified hepatology as an area of focused competence (AFC) and offered diploma status in 2015. It is beyond the scope of this editorial to describe the entire process involved in achieving this milestone, but it is of interest (albeit historical) to note that a similar undertaking was initiated twenty years earlier. Specifically, in 1991, CASL submitted a proposal to the RCPSC requesting that hepatology be designated a distinct sub-specialty within the domain of internal medicine. The proposal outlined the prevalence of hepatobiliary disorders in Canada, the rapidly expanding repertoire of diagnostic and therapeutic modalities, the research being conducted at various Canadian institutions, and the establishment of specific hepatology training programs (in Manitoba and Quebec). Letters of support were provided by Drs Eldon Shaffer, Jenny Heathcote, Laurie Blendis, and Carl Goresky. The RCPSC response was encouraging. The proposal would be accepted contingent on CAG, the parent organization, providing their approval. Unfortunately, the CAG president unilaterally refused to provide that approval, his argument being that liver disease patients constituted an appreciable percent of a gastroenterologist’s patient population (estimated 25%); hence, the loss of income to CAG members would be substantial. The counter-argument (and argument is the best word to describe the exchange) of ensuring optimal patient care fell on deaf ears and the initiative was laid to rest. That is until Dr Eric Yoshida resurrected the cause and, with much time, effort, and his well-developed powers of persuasion, finally brought CAG on board and secured its approval.

Strike one: Termination of “Discover the world of hepatology”

Growth and renewal are essential to the long term success of any medical discipline. Hepatology is no exception. Recognizing the need to attract new individuals and replace departing hepatologists, the Section of Hepatology at the University of Manitoba (U of M) embarked on an ambitious program in 2008 to put hepatology on the radar screen of undifferentiated internal medicine (IM) trainees. The Canadian Liver Foundation (CLF) was very supportive and generously agreed to cover the costs of two IM trainees from each of the country’s major academic centres to attend a 1–2 day symposium describing what a career in hepatology would entail (2). The symposium was hosted by U of M faculty and supplemented by national opinion leaders from other Canadian centres. From this initiative, many of Canada’s present hepatologists first became aware of the discipline, committed themselves to additional training in the field, and selected hepatology as their ultimate career path. Unfortunately, the symbiotic relationship between the U of M and CLF ended when the CLF decided the program should be assigned to CASL, and interest/enthusiasm quickly waned. It needs to be resurrected.

Strike two: Lack of uptake

For as long as there are substantial differences in the incomes of gastroenterologists and hepatologists, the majority of individuals dual trained in gastroenterology and hepatology will eventually transition into G-WILDs. Hence, there must be a path forward to a career in hepatology that does not involve 3–4 years of accredited GI training. The argument that only someone trained in GI can best manage patients with gastrointestinal bleeding is specious. Yes, GI bleeding occurs in liver disease patients but so does insulin resistance, yet we don’t insist that budding hepatologists train in endocrinology! To this end, the University of Manitoba and Université de Montréal developed specific hepatology training programs that do not require previous, concurrent, or subsequent training in gastroenterology. Of note, graduates of these programs have had no trouble finding positions in Canada and elsewhere as ‘pure’ hepatologists or hybrid hepatologists/internists. But the uptake for similar training programs in other centres has been disappointing. Clearly, this is a missed opportunity and represents an important second strike against Canadian hepatology.

Next pitch

Now that we are at full count, the next pitch may well determine the outcome of Canadian hepatology. If it is a ball, such as having the Canadian Liver Journal indexed by PubMed, we will take an important step towards success. If a strike, such as reintegrating our annual CASL meetings into CAG days, we will be ‘out’ and have to wait some unknown period of time for our next at bat. But there’s a third possibility, a pitch we could hit ‘out of the park,’ the proverbial home run: RCPSC recognition of hepatology as a distinct sub-specialty. This recognition would allow university funding of hepatology fellowship positions and diminish the need for training sites to apply for support from the CLF and industry. Although contingent on RCPSC resuming sub-specialty recognition, we must, nevertheless, be fully prepared for this important pitch.

Disclosures:

The author has nothing to disclose.