Goals and Objectives
The goal of the core training program in Hepatology is to teach the fellow the methods and mechanisms of diagnosing, managing, and treating hepatobiliary disorders, either alone or in the setting of concurrent medical problems. These goals are achieved largely while rotating on the hepatology consultative service which includes a weekly clinic. Training in liver disease also takes place on the endoscopy rotations and various other settings. During the first 12 months of clinical (core period) training the fellow will accumulate significant experience with the common and unusual hepatobiliary diagnoses, the complications of acute and chronic liver disease, the role of liver biopsy and radiographic investigations (including invasive radiology i.e., transjugular intrahepatic portosystemic shunt (TIPS), portal venography, arteriography, and wedged hepatic vein pressure measurements), and the technique of liver biopsy. There is ample opportunity on the hepatology rotation to interact in a meaningful way with physicians from a variety of disciplines and manage complex, multifaceted disease processes in a coordinated way. Fellows will learn the natural history of liver disorders and risk of procedures (including surgical procedures, i.e. cholecystectomy in a cirrhotic patient) in the management of patients with liver disease.
Specific Learning Objectives in Core Hepatology Program
Fellows will acquire expertise in:
- The evaluation of abnormal liver enzymes
- The assessment and therapy of jaundice
- The assessment and therapy of acute and chronic liver disease including alcoholic, drug-induced, autoimmune, viral, cholestatic, and metabolic liver diseases
- The evaluation and therapy of complications of liver disease including portal hypertension, ascites, hepatic encephalopathy
- The diagnosis and management of hepatobiliary neoplasms
- The diagnosis and management of biliary tract stones
- The assessment and therapy of hepatobiliary manifestations of HIV disease
- The approach to surgical risks in patients with liver disease
- Liver biopsy techniques
- The assessment and endoscopic therapy of gastrointestinal bleeding (i.e. sclerotherapy or vanceal banding) in patients with liver disease.
Required Procedural Skills
The trainee must acquire competence in the performance of the following procedure in addition to understanding their indications, contraindications, limitations, complications, and interpretation:
- Performance of percutaneous liver biopsy: minimum 20
- Diagnostic and therapeutic paracentesis: minimum 20
Sites of hepatology learning are the inpatient wards of the UTMB hospital, including the internal medicine, pediatric, psychiatric, geriatric, surgical, obstetrics, family medicine, and neurology services, and the Texas Department of Criminal Justice (TDCJ) hospital. Additional hepatology training occurs in the outpatient clinics of the UTMB Hospital, the TDCJ hospital, the GIM- Maroon Team and the Surgical Liver Transplant Service.
For the inpatient experience, there is one hepatology attending who is the primary teacher for the fellow during that month. Additional input to the development of the fellow comes from the weekly clinical case conference, pathology conference and radiology conference. It is routine that the hepatology team reviews all liver biopsies from patients on the hepatology service with an expert in hepatic histopathology. Each new consultation is seen under the personal guidance and review of the hepatology attending at the bedside and at all sites of primary information (i.e. radiology, pathology). The historical information, physical exam findings and laboratory data from the case are reviewed in light of both recent and time-honored literature and personal experience of the attending. A thorough assessment and plan are agreed upon and proper communication to the primary attending physicians and the patient and his/her family is emphasized.
The hepatology fellow is involved in providing care in the weekly outpatient TDCJ gastroenterology clinic that is populated by roughly 50% of hepatology patients. There is further hepatology experience in the UTMB outpatient fellows' gastroenterology clinics that are supervised by divisional attendings on a monthly basis. The principles of cost effective assessment and rational use of diagnostic test and therapies are emphasized especially in the outpatient environment.
The fellow is expected to teach as well as learn. There is an extensive curriculum file in the gastroenterology library and there are individual computers for each fellow and textbooks of hepatology in the fellows' office for the purpose of literature review and consolidation of knowledge concerning cases seen in various clinical settings.
Method of Evaluation
Faculty observe the fellow's skill and competence in history taking, physical exam, judgment, and consulting skills for an entire month by daily rounding with the fellow and meeting to discuss in-depth problems or unusual cases. Technical competence in endoscopy and liver biopsies is observed first hand by the attending in the Endoscopy Unit as well as the Hepatology attending. Communication skill, attitude and behavior are assessed through close association through the month. At the end of the month, the hepatology faculty member completes a numerical ranking form and supplies extra comments for the ultimate assessment of the fellow by the Chief of Gastroenterology. The fellows also assess the Hepatology rotation and the faculty attending. The evaluation process is described more fully in the previous section on Method of Evaluation under Gastroenterology Consult Rotation.
The department of internal medicine is developing evidence based clinical protocols which will be available in EPIC (as order sets) for use when admitting patients with these diagnoses. Their AIM is to standardize care and decrease length of stay and readmission rates.Currently available protocols are:
- CAP - Community Acquired Pneumonia Orderset
- Congestive Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetic Ketoacidosis Adult, ICU
- General Medicine Admission
- Immunodeficiency Flow Panel
- MICU/CCU Admission Order Set
- Oral Analgesic Medicaitons
- Parenteral Opioids
- Sepsis, Adult ICU
- 111 - Stroke Alert
- 112 - Stroke Activation
- 300086 - Stroke Floor Admission
- 3000000001 - Stroke Critical care without tPA
- 300088 Stroke - Transfer from Critical care to floor
- 3004002 - Stroke Discharge
All protocols can be found in the EPIC order set section.
The department of Internal Medicine has a large role in the Meaningful Use Initiative. Our participation is key for the success of the initiative. Please visit the meaningful use website for important communication and updates from the Meaningful Use Initiative.