Revised November 2018
A competency-based training program sponsored by the AASLD and the American Board of Internal Medicine (ABIM) that grants exceptions to individual trainees to focus on achieving competency in transplant hepatology during the third year of gastroenterology fellowship using an outcomes based approach to the design, implementation, assessment and evaluation of their training.
For individual fellows, a benefit is the use of a competency-based model to reduce training time required to become certified in both GI and transplant hepatology. These fellows are likely to enjoy increased attention from program directors and other core faculty. Individual training programs benefit from a highly motivated and focused fellow. Many GI fellowship programs are seeing an increase in applicants with an interest in hepatology who are seeking programs that offer the pilot pathway. Transplant hepatology was one of the first specialties to formalize and implement competency-based training. Individual fellows and programs benefit from pioneering this new training paradigm by advising the AASLD and ABIM about best practices. Lessons learned from the pilot will undoubtedly be used in other competency-based frameworks. If successful, the pilot pathway will become an accepted training track toward GI and transplant hepatology certifications. Most importantly, employers, patients and society will benefit from a group of providers who have demonstrated competence in GI and transplant hepatology through a rigorous training program utilizing innovative assessment methods and established competency standards.
The pilot functions via ABIM-granted individual exceptions to training and therefore does not require ACGME Internal Medicine Review Committee approval.
Yes. ABIM has approved 3 competency-based medical education pilots including GI/transplant hepatology. The other pilots are geriatrics/palliative medicine and internal medicine/cardiology. All 3 pilots differ substantially in goals and structure but all share the goal of using competency-based assessments in innovative ways.
Any fellow in an ACGME-accredited gastroenterology program that is affiliated with an ACGME-accredited transplant hepatology fellowship. The fellow must be ABIM-certified in Internal Medicine at the time of submitting the application for the pilot program. Fellows in the ABIM GI Research Pathway, which shortens Internal Medicine training to 2 years, are not eligible for this pilot program.
The fellow applicant must complete all clinical gastroenterology requirements before the end of the second year of gastroenterology fellowship and must be on a trajectory to achieving competence for the unsupervised practice of gastroenterology by the end of the third year, with the expectation that the majority of the third year is focused on transplant hepatology training. The applicant must have the support of both gastroenterology and transplant hepatology program directors and the chair of the gastroenterology Clinical Competency Committee to apply for the pilot program. The fellow applicant and program must agree to use required assessment tools and respond to surveys and other data requests for tracking and oversight of the pilot program.
This has not been determined. A final decision about the fate of the pilot and whether it should become a standard training pathway may take several more years.
The pilot program is a clinically-focused track that is appropriate for those interested in a career focused on clinical advanced/transplant hepatology. If you are considering an academic career with a substantial research focus, additional time in GI fellowship is necessary before pursuing the mostly clinical 4th year transplant hepatology fellowship. Duration of training is an important factor but should not be the only reason to pursue the pilot program. Some trainees may need the standard 3 years to achieve competence in GI to be ready for unsupervised practice. Others may wish to use the 3rd year of GI to pursue other interests including research or a Master's degree.
These concerns are program-specific and cannot be answered across the board; it will be an ongoing learning process. Although each individual program has "specifics" that may not be shared by other programs, open communication between program directors will be beneficial to share experiences, preempt problems and enhance problem solving of such issues across programs. In particular, funding for the pilot fellow is program-specific and may be part of the complement of GI fellows or through other mechanisms. Many GI programs are finding that the pilot is a desired option for many applicants and can be used as a recruiting tool for highly qualified applicants interested in a career in transplant hepatology. Going forward the experience/data gathered from the leading pilot programs will constitute the threshold on which joining programs may build and benefit from, to better plan for and execute the pilot year.
Yes. Candidates will be informed by the ABIM of their enrollment in the pilot and receive documentation that they are being granted an exception to existing ABIM training requirements that will allow them to sit for certification in both gastroenterology and transplant hepatology upon successful completion of the pilot.
The pilot fellow will be eligible to sit for both specialty certification examinations after completing the 3- year pilot (third year of GI). As per current requirements, the fellow cannot register for the transplant hepatology exam until passing the GI exam. Because the transplant hepatology exam is offered every other year, in some cases the pilot fellow will need to wait 2 years after completion of training to take the transplant hepatology exam. If requested, ABIM can provide a letter attesting to completion of the unique training pathway while the fellow is waiting to take the exam if needed for prospective employers.
No. Please contact the ABIM directly for questions about your specific situation.
Since the pilot program may be perceived as a new training track within GI, it is best to involve the Designated Institutional Official (DIO) and GME Committee early. The application requires the program to attest that the DIO and GME Committee have approved the pilot program.
No, unless your institution applies for accreditation for a transplant hepatology fellowship program through ACGME.
A transfer may be considered only in unique and extenuating circumstances. Requests for such an exception must be made to the Pilot Steering Taskforce in advance (before the application deadline) and will be considered on a case-by-case basis.
Fellows should inform their GI fellowship program director as early as possible of their interest, and program directors should notify the Pilot Steering Taskforce as early as possible (generally in the first year of GI fellowship). The prospective pilot fellow and both GI and transplant hepatology program directors are responsible for ensuring that most clinical GI requirements are completed by the end of the second year and that the prospective pilot fellow is on a trajectory to achieve competence in GI by the end of the third year, taking into account that the third year will be focused on development of competence in transplant hepatology. In practice, this means that most, if not all, clinical GI requirements must be completed by the end of the second year. It is not necessary to include 5 months of general hepatology training in the first 2 years but some hepatology training is required before entering the pilot year.
The GI and transplant hepatology program directors and prospective pilot fellow need to submit an application to the Pilot Steering Taskforce during the fellow's second year. Applications are generally available in December of the year prior to the start of the pilot year. At that time, application materials are forwarded to program directors upon request from the Pilot Steering Taskforce. The Pilot Steering Taskforce will review the application materials and issue formal approval, at which time the fellow's name will be forwarded to ABIM for tracking and certification purposes. This is not a competetive process; all fellows who meet the criteria will be approved.
No. The criteria for entry into the pilot include a determination by the GI Clinical Competency Committee that the fellow is on a trajectory to achieve competence in GI by the end of the third year. This generally cannot be determined prior to the start of GI fellowship and is best assessed late in the first year or early during the second year of fellowship. A GI fellow applicant cannot be promised a spot in the pilot program because the fellow must achieve certain milestones that demonstrate development of competence before acceptance into the pilot program. In cases where the fellow is not on a trajectory to achieve competence in GI by the end of the third year, as determined by his/her performance by the end of the first year or the beginning of the second year, that fellow will not be allowed to enroll in the pilot program.
No. The GTE is a formative exam used for continuous improvement of the fellow and the program. It should not be used to justify promotions or deny advancement and it should not be used as a criterion for entry into the pilot program.
This award has been established to encourage academic careers of hepatology trainees rather than to provide salary support. It is open to 4th year fellows and to fellows in the pilot program. The application deadline for this award is in December, several months before the application deadline for the pilot program itself. Since eligibilty for the award is contingent upon acceptance into the pilot program, we encourage interested applicants/programs to apply to the pilot as early as possible. A GI fellow interested in both the pilot program and this award will need to apply for the award early in the second year of GI. The pilot application includes a checkbox to notify AASLD of the intent to apply for this award if applicable. Learn more.
Yes. A program should not apply unless and until it has an appropriate fellow. Programs and fellows are considered and approved on a case-by-case basis each year.
Thirty-five (35) programs have participated or are participating this year and are listed below. This represents 67% of the 52 accredited transplant hepatology fellowship programs. These programs may or may not participate in future years, depending on whether they have an appropriate fellow, and these are not the only programs that may participate in the future. Any program that has an ACGME-approved GI fellowship program and an ACGME-approved transplant hepatology fellowship program is eligible to participate. Prospective pilot fellows should check with individual GI or transplant hepatology fellowship programs directly to find out if they are offering this pilot pathway as an option.
Seventy-four (74) fellows have participated in the pilot program so far, including this year.
All pilot fellows who have taken the GI ABIM certification exam have passed, and all who have taken the transplant hepatology ABIM certification exam have passed. Results of the October 2018 exams were not available at the time of this writing.
The transplant hepatology program director and the pilot fellow will each be required to complete surveys during the course of the pilot that includes the types and frequency of assessments used in reaching an evaluation of competence. These requirements are in addition to ACGME reporting requirements including Reporting Milestones. Pilot fellows must agree to some modest reporting expectations following their graduation from the pilot program (e.g., nature and location of subsequent faculty position, whether the graduating fellow remained in the field of transplant hepatology, etc.) and are required to provide contact information following graduation. The Pilot Steering Taskforce may request permission to contact the pilot fellow's chief/supervisor following graduation for assessment/feedback after the pilot fellow has been in practice for at least one year.
We support the experience of the pilot fellow to ensure continued exposure to GI so that the fellow can continue to work toward achieving competence in GI and to facilitate passing the ABIM certification examination. These activities may include attendance and participation at GI conferences, participation in GI continuity clinic and GI call.
No. The required attendance at conferences should not increase, but should be blended to reflect the required exposure to each specialty.
Yes. The pilot fellow must meet the requirements of the accredited transplant hepatology fellowship even if there are no 4th year transplant hepatology fellows. This means the program must have a curriculum and conferences that are separate from the GI curriculum/conferences, as specified in the transplant hepatology program's application submitted to ACGME.
The pilot fellow should not participate in therapeutic endoscopy procedures or consultations and should not act as “chief GI fellow” during the pilot year.
No. However, we expect that the fellow will engage in some general hepatology clinical training during the first 2 years of fellowship. There should be sufficient exposure to hepatology to gauge the fellow's level of interest in transplant hepatology, to be sure the fellow will commit to training in transplant hepatology and will remain in the field. There should be sufficient exposure to hepatology to provide the transplant hepatology program director with an indication of how the fellow will perform in the pilot program and that the fellow is appropriate for the pilot. In practice, we recommend at least 2-3 months of general hepatology clinical training before entering the third year.
We recognize this trade off between achieving clinical competency and pursuing scholarly activity. The pilot fellowship program is an intensive clinical track that will substantially decrease the time available to focus on research and other scholarly activities. This underscores the importance of selecting the appropriate fellow for the pilot program. Fellows who wish to focus on research may not be appropriate for the pilot program and should remain in the traditional track by completing 3 years of GI training before pursuing transplant hepatology training. This includes fellows funded by a T32 grant as there will not be sufficient time to fulfill requirements for research training and clinical GI training in a 2-year period prior to starting a pilot year. Pilot fellows must still fulfill the ACGME requirement to participate in research or other scholarly activities and this requirement is included in the ACGME Subspecialty Reporting Milestones as a distinct subcompetency for all Internal Medicine subspecialties.
No. See the question above "What about scholarly activity?"
The pilot program is in the "testing phase," and is not currently replacing the 4th year. The pilot was not designed to replace the 4th year track and may continue to co-exist in programs that have the capacity to train 2 or more transplant hepatology fellows per year.
One of the most important criteria for applying to the pilot program is that the program must attest to the applicant's developing competence and the trajectory of the applicant toward competence in GI by the end of their third year. The CCC is in the best position to attest to the applicant's competence and we therefore want to emphasize the importance of the role of the GI CCC chair in this process.
ACGME will only require Reporting Milestones for the pilot fellow to be completed by the transplant hepatology program director (in the winter and early summer reporting windows of the pilot year). The Reporting Milestones should be completed with substantial input from the GI program director and the GI CCC, reflecting the competence of the pilot fellow in GI milestones during the third year. It is recommended that the GI program director participate in the transplant hepatology CCC meetings and/or the transplant hepatology program director participate in the GI CCC meetings when the pilot fellow is discussed.
"Entrustable Professional Activities (EPAs) are those professional activities that together constitute the mass of critical elements that operationally define a profession." (ten Cate O, Scheele F. Academic Medicine 2007;82:542-7). Supervising faculty assess the competence of a trainee through direct observation of the performance of these activities. Each EPA represents various competencies and milestones of professional development. Use of EPAs is the cornerstone of assessment within this competency-based medical education pilot.
The ABIM Mini-Clinical Evaluation Exercise (Mini-CEX) is a 10-20 minute direct observation assessment or “snapshot” of a trainee-patient interaction. The faculty member provides timely and specific feedback to the trainee after each assessment of a trainee-patient encounter. The Mini-CEX need not assess a complete patient encounter and can be used to assess a specific part such as counseling, which may be most appropriate for fellows at this advanced level of training. Mini-CEX booklets can be ordered from ABIM free of charge. The Mini-CEX [PDF] can be distributed for demonstration during faculty workshops, staff meetings, orientation and training sessions. The pilot requires that the Mini-CEX be administered at least quarterly.
Not at this time. This will not be a required assessment until it becomes available to all pilot programs.
Fellows must participate in training using simulation (ACGME Transplant Hepatology Program Requirements). Simulation does not require the use of high-tech models and can be as simple as simulating a patient case presentation with the trainee. Liver biopsies lend themselves well to training and assessment through simulation, but this is only one example of the use of simulation in transplant hepatology training.
Portfolios are not a required assessment tool for the pilot or for transplant hepatology training in general. Portfolios can be a useful assessment tool in both undergraduate and graduate medical education and can be used as a tool for trainees to record their accomplishments, reflect on their experiences and obtain formative feedback. In practice, portfolios may be difficult to implement in fellowship training. There are many platforms available and we are unable to recommend a specific platform.
Through the Transplant Hepatology Program Directors' Listserv and on the AASLD and ABIM websites.
This is up to the individual program, but we recommend 2 certificates reflecting the achievement of competence in 2 distinct specialties, GI and transplant hepatology.
Oren Fix, MD, MSc, FAASLD (Chair)
Swedish Medical Center, Seattle, WA
Steven Herrine, MD, FAASLD
Thomas Jefferson University, Philadelphia, PA
Ayman Koteish, MD, FAASLD
Florida Hospital Transplant Institute, Orlando, FL
Gautham Reddy, MD, FAASLD
University of Chicago, Chicago, IL
Mark Russo, MD, MPH, FAASLD
Carolinas Medical Center, Charlotte, NC
Richard Sterling, MD, MSc, FAASLD
Virginia Commonwealth University, Richmond, VA
If the pilot fellow takes up an already approved transplant hepatology fellow position, then no further action regarding fellow complement is needed. If your program intends to fill all approved transplant hepatology positions with 4th year fellows AND wishes to participate in the pilot during the same year, then you will need to justify this increase in transplant hepatology-trained fellows to the ACGME by applying for a temporary or permanent complement increase. The ACGME Internal Medicine Review Committee should not have an issue with this (the educational justification is the pilot program itself) as long as the program has sufficient core faculty and resources to train the additional fellow. It is the individual program's responsibility to apply for the complement increase. This is done through ADS and involves your GME committee and DIO.
Previously, we have asserted that the ACGME "double-counted" the pilot fellow as both a GI fellow and transplant hepatology fellow during the pilot year. This is no longer true, meaning a program has the option to recruit an additional GI fellow to replace the vacant spot left by the pilot fellow. If the pilot fellow is unable to complete the pilot program for any reason, the pilot fellow will need to be reintegrated into the GI fellowship program to complete his/her GI fellowship requirements. If the program has filled its complement, it will need to request an increase in complement from the ACGME in order to accommodate this reintegration. Some programs may not be able to add another GI fellow because of local availability of GME funding.
Yes, but some programs may risk losing available funding for the 4th year position if it remains unfilled.
ADS cannot have a trainee marked as actively training in two separate programs during the same time period. After the end of the second year of GI training, pilot fellows should be marked as "Completed" in the GI program and marked as "Active Full Time" in the transplant hepatology program.
Follow these steps:
Both the Resident Survey and Faculty Survey will then be scheduled for the final reporting period during the pilot year.
While it may seem incorrect to designate the pilot fellow as "Completed all accredited training-successfully promoted" at the end of the second year, be assured that this does not mean the fellow will be able to skip the pilot year and become certified in GI after only 2 years of training. Certification in GI still requires 3 years of training, inclusive of the pilot year. The process outlined above is necessary for ACGME tracking purposes because ADS is not designed to specifically accommodate the unique situation of the pilot, as well as to ensure that the Faculty Survey and Reporting Milestones are completed by the appropriate faculty.
If the pilot fellow is unable to complete the pilot program for any reason, he/she will need to be changed in ADS from transplant hepatology back to GI.
We will permit the pilot fellow to remain in ADS as a GI fellow on a case-by-case basis if you are not comfortable with this process or your program needs the fellow listed in GI rather than transplant hepatology for funding purposes. Please contact the Pilot Steering Taskforce to discuss your program's specific needs if necessary.
For the purposes of eligibility for certification in both specialties, ABIM needs confirmation of both the GI and the transplant hepatology general and procedural competencies of the pilot fellow. Therefore, programs will need to complete separate evaluations for GI and transplant hepatology.
The Pilot Steering Taskforce is charged with ensuring that the clinical environment that will train the prospective pilot fellow is in good standing with the ACGME and is well suited to participate in this unique training program.