Beyond Fellowship….. Seeking Additional Training

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Beyond Fellowship..Seeking Additional Training

• GI Division Rounds
• Brian Brauer, MD
• February 14, 2006

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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

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What

• Advanced Endoscopy
• Transplant Hepatology
• IBD
• Motility
• Other organ specific programs esophagus,
  pancreas, etc. If theres an organ, Mayo has a
  program for it

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Things to Consider

• How to find programs Is it a secret?
• Funding
• Accreditation
• Experience
• Additional responsibilities
• Time commitment
• Application timetables

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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• Most lists are outdated

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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 werent listed elsewhere)

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Finding programs
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Funding

• These are non-ACGME accredited fellowships most
  GME departments dont 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)

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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

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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 dont believe it is possible to
  become truly proficient in both ERCP and EUS

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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?

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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?

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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

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Endoscopy
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Endoscopy

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

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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

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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.

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ERCP Requirements

• ERCP 180-200 procedures recommended, at least
  50 with a therapeutic component (sphincterotomy,
  stone extraction, lithotripsy, stricture
  dilation, stent placement, cholagioscopy/pancreato
  scopy)
• Cases in which native anatomy is altered (prior
  sphincterotomy, routine stent change) excluded
• Cannulation of desired duct with gt80 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

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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 ERCPs unsupervised following training
• Kowalski et al., GIE 2003

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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 199949829-33

Faigel D et al. Ensuring Competetency in
Endoscopy. ASGE/ACG 2005.
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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 199949829-33

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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

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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
  yearpreferably one related to therapeutic
  endoscopy
• provide an exposure to endoscopy unit management
  (scheduling, staffing, equipment maintenance,
  management skills, etc.)

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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

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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

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Transplant Hepatology
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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

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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
  2002885-7.

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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
  2002885-7.

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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 ASTs 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
  2002885-7.

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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
  2002885-7.
• AGA Core Curriculum, 1996.

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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.

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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, nonheart-beating donors, criteria
  for brain death, and appropriate recipients.

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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.

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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.

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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
  2002885-7.

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Where to Find Programs

• AASLD provides a list of programs, this list
  includes all liver transplant programs
• https//www.aasld.org/eweb/DynamicPage.aspx?SiteA
  ASLD3WebKeyf4c4c8ab-0ed2-4d70-9ab2-c03458f668a9
• Does give listing of volume and fellowship slots

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Other Resources
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Inflammatory Bowel Disease
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Inflammatory Bowel Disease

• Duration 1-2 years depending on research
  requirement
• Less structured and regulated than other advanced
  training programs

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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.

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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.

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Help is on the way.
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Other Subspecialties
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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

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Motility
AGA Core Curriculum
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Where to Find Programs

• Mainly word of mouth ask the experts in the area
  of interest

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Summary

• There is wide variation in structure and and
  philosophy or advanced training programs
• Start early if youre 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 dont go to a program expecting
  training in an area it doesnt claim to provide

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