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Pursuing a Career in Hepatology

Considerations for Gastroenterology Fellows

Sadowski, Brett W.1

doi: 10.14309/crj.0000000000000085

1Department of Medicine, Gastroenterology Service, Walter Reed National Military Medical Center, Bethesda, MD

Correspondence: Brett W. Sadowski, MD, Department of Medicine, Walter Reed National Military Medical Center, Gastroenterology Service, Building 9, Rm 1440, 4494 North Palmer Rd, Bethesda, MD 20889 (

Online date: May 16, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Like many fields within the practice of medicine, transplant hepatology (TH) has undergone incredible growth and change over the course of the past half a century. Through the work of thousands of researchers, clinicians, and patients, the discipline has evolved to take its position at a critical crossroads between general gastroenterology (GI) and multiple medical and surgical subspecialties. In addition to medical complexity, TH has an additional component of societal ethics in regard to precious resource utilization and stewardship. There is little doubt that transplant hepatologists will play an increasingly more pivotal role in the next few decades as hepatitis C and alcohol-related chronic liver disease yields to the tsunami that is nonalcoholic fatty liver disease as the leading causes of cirrhosis and liver-related morbidity and mortality. Passionate clinicians and pioneers in research are essential to fill a burgeoning need in our country while advocating for our highest risk patients.

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I became interested in TH for many of the same reasons I went into internal medicine. I was drawn by the intrapersonal relationships one can build with individual patients and families before, during, and after the most trying periods of their lives. Contributing to the field's allure are these relationships, coupled with a tremendous breadth of pathology and the opportunity to maintain core endoscopic skills. The relative reduction in procedural volume may be a deterrent to some, but for me, the intellectual opportunity and ethical components inherent to the field is well worth less endoscopy volume. While choosing a subspecialty is an intricate personal decision, TH has something to offer any one with clinical, research, or procedural interests.

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The path to TH has changed over the past few years to help address the gap between the supply of and demand for these specialists. Options for sequential clinical training after completing fellowship in GI or through competency-based, clinically focused training completed within a 3-year combined GI/TH pilot are available at many of the 52 training programs nationwide. The majority of centers limit this program to trainees in their own GI fellowship. Many programs suggest 3 letters of recommendation highlighting a candidate's potential for future development as a hepatologist.

Completion of the traditional 3-year GI fellowship affords dedicated research time that can be used to enhance a candidate's application beyond the expected clinical preparation. This could be more appropriate for candidates who wish to pursue academic career with focus on research.

The alternative pipeline was developed as an innovative attempt to fill unmet needs for trainees while addressing the concerns of many applicants regarding extension of training. Eligible trainees who can complete GI clinical requirements within 24 months and are on a trajectory to fulfill all core competencies within 3 years may request combined “pilot” training through the American Association for the Study of Liver Diseases Pilot Steering Taskforce in conjunction with the Accreditation Council for Graduate Medical Education and American Board of Internal Medicine. This program puts a priority on clinical preparation ensuring that candidates are well trained in core gastroenterology. Although some academic engagement is important for well-rounded applicants, the reduction in dedicated research time in the first 2 years of training may impact candidates' productivity in favor of clinical training. As a competency-based program, the pilot program provides an exciting opportunity for those who are clinically focused and are on track to be ready for unsupervised practice. Early communication with your gastroenterology program director and possible TH program directors, as well as ensuring competence in GI and pursuing personal academic interests early in training, is essential for this pathway.

The field of hepatology, in particular TH, continues to play an ever-increasing role in American healthcare. Innovative training opportunities exist for you to pursue challenging careers working hand-in-hand with patients and care teams to not only help individuals, but also serve as leaders and stewards of our healthcare system.

© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.