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Outpatient Hepatology/Transplant Hepatology  D. Inpatient Transplant Hepatology

Overview

Throughout the training program, the fellows are exposed to general Hepatology during Inpatient Consult Service, during outpatient Liver Clinics, and during their own Fellow’s Continuity Clinic.  

In addition, a 4 month rotation in outpatient Transplant Hepatology is provided in the second year; a 2 month rotation in inpatient Transplant Hepatology is provided in the second year; and a 2 months rotation in inpatient Transplant Hepatology is provided in the third year.  This provides a more intense and focused exposure to the management of the pre- and post-transplant patient with liver disease.  Currently there are approximately 50 liver transplants performed per year.

The fellow may be involved in the supervision of any medical residents or students electing the rotation in Hepatology.

Principal Teaching / Learning Activities

For the outpatient rotation, fellows will participate in a general Hepatology clinic each week, during which they see from 2-3 new outpatient consults per session, and 4-6 follow up visits.  Fellows will participate in 4 half-day multidisciplinary Transplant Hepatology Clinics per week. Fellows will perform complete history and physical examinations, review laboratory data including actual Radiology studies, formulate differential diagnoses, and formulate a plan or set of recommendations, including timing of intervention and/or follow up.  After presentation and review with the Attending physician, the fellow will generate documentation for the encounter.  Fellows will participate in any procedures, including liver biopsy if interested, for these patients during their rotation.  For the inpatient rotation, the fellows will participate in teaching rounds with the Attending Hepatologist, which involves the inpatient care of imminently pre-transplant patients, and the post-operative liver-transplant recipients.  Fellows will serve as a supervisory consultant to any house officers and/or mid-level providers on the inpatient Liver service, while the service is staffed by a board certified Transplant Hepatologist.  Fellows will write daily progress notes during the week days for these patients. Order entry will remain the responsibility of the house officers and/or mid-level providers on the Liver service, and will not be the responsibility of the rotating GI fellow.    

Problem mix / Patient characteristics / Types of encounters

The fellow is exposed to a wide variety of liver diseases, including but not limited to acute and chronic viral hepatitis, alcoholic hepatitis, autoimmune hepatitis, cholestatic liver diseases (primary biliary cirrhosis, primary sclerosing cholangitis, drug-induced liver disease, etc.), fatty liver and non-alcoholic steatohepatitis, hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, and infiltrative liver diseases.  Inpatients of various levels of clinical acuity, as well as ambulatory outpatients are seen.  Complications of cirrhosis including bleeding of portal hypertensive origin, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, coagulopathy, fulminant hepatic failure, and hepato-pulmonary complications will be encountered.

Purpose and Principal Educational Goals by Competency

Patient Care

Principal Educational Goals

  • Learn the elements of history pertinent to the evaluation of the patient with liver disease.
  • Learn the elements of physical examination and how to elicit subtle findings pertinent to the evaluation of the patient with liver disease.
  • Learn the laboratory and radiologic studies pertinent to the evaluation of patients with liver diseases.
  • Learn to formulate a focused differential diagnosis in patients being evaluated for liver disease.
  • Learn to formulate rational management plans for patients with liver disease.
  • Learn the indications, contraindications and alternatives to percutaneous liver biopsy.
  • Be familiar with the role/indication/evaluation process for liver transplantation in patients with liver disease

Medical Knowledge

Principal Educational Goals

  • Expand the fellow’s knowledge base of the basic and clinical science that underlies the practice of Hepatology.
  • To critically evaluate current medical information as pertains to Hepatology.

Practice-Based Learning and Improvement

  • Identify gaps in personal knowledge and clinical skills in the consultative assessment of clinical disorders and problems in Hepatology.
  • Implement strategies for correcting these deficits.

Interpersonal Skills and Communication

Principal Educational Goals

  • Communicate effectively with patients and families.
  • Communicate effectively with referring physicians and other members of the health care team.
  • Coordinate urgent inpatient care effectively to avoid unnecessary delays in diagnostic or therapeutic procedures.
  • Teach and supervise residents and students effectively.
  • Present patient information clearly and concisely, verbally and in writing.
  • Identify and communicate on issues of a sensitive nature, such as end-of-life issues and sexual transmission of viral disease.

Professionalism

Principal Educational Goals

  • Demonstrate respect, compassion, and honesty in relationships with patients, families and colleagues.
  • Demonstrate a willingness and enthusiasm for work.
  • Demonstrate sensitivity to patients and colleagues on issues of gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities.
  • Adhere to principles of patient confidentiality.
  • Practice informed consent and informed refusal.

Systems-Based Practice

Principal Educational Goals

  • Demonstrate the ability to cooperate and collaborate with colleagues in other disciplines for complex patient problems that require multidisciplinary management.
  • Use evidence-based, cost-conscious strategies in the management of patient problems.

Evaluation

Fellow’s performance is evaluated by faculty as discussed in detail later, and additionally at the end of each rotation.

Recommended Reading

The Hepatology section of the general Gastroenterology texts provides an excellent overview of the field.  Further in-depth reading is recommended in dedicated Hepatology texts, such as either Zakim and Boyer’s Hepatology – A Textbook of Liver Disease, or Schiff’s Diseases of the Liver.  As always, the most current medical information should be gleaned from computerized data bases, such as UpToDate.