An Analysis of the Variables Affecting Gastroenterology Fellow Decisions to Pursue Hepatology Careers

Rohit Satoskar^*
*Correspondence: Rohit Satoskar, Department of Gastroenterology and Hepatology, University of Medstar Georgetown, Washington, D.C, USA, Email:

Description

Over the past two decades, the burden of chronic liver disease has significantly increased in the United States. Chronic liver disease with cirrhosis is the twelfth leading cause of death overall and the fifth leading cause of death in patients between the ages of 45 and 54.The number of people with cirrhosis in the United States is 633,323, or 0.27 percent of the population, and many cases go undiagnosed. New hepatitis C screening recommendations, an increasing immigrant population with chronic hepatitis B and the worsening epidemic of obesity-related liver disease promise to increase the need for specialized care for these patients. The continued success of liver transplantation for an increasing number of chronic liver diseases also requires physicians who are trained in the care [1].

More hepatologists need to be trained. In 2009, the American Association for the Study of Liver Diseases (AASLD) had approximately 3,500 members who paid their dues, with half of those members residing in the United States. A recent estimate in the United States indicated there are "a thousand or so hepatologists to serve our communities," or an average of one hepatologist for every 330,000 individuals. The need to train additional hepatologists to meet rising demand is evident. Only half of those surveyed indicated that they or the majority of their practice focused on patients with liver disease. Of the liver transplant programs surveyed, 81% reported they were recruiting or would be recruiting additional hepatologists within the next three years, with many recruiting for two [1].

As a subspecialty of internal medicine and gastroenterology (GI), hepatology is still in its infancy. The dedicated clinical practice of hepatology began in the late 1990s, and in 2002, curricular guidelines for training in transplant hepatology (TH) were published. In 2006, the first TH certifying exam was offered by the American Board of Internal Medicine (ABIM). Currently, only gastroenterologists with ABIM certification are eligible to train and become certified in TH.A three-year internal medicine residency, a three-year GI fellowship, and a one-year TH fellowship are typically required for certification in TH. In recognition of the lengthy training process and to meet the growing demand for hepatologists, the ABIM and the AASLD Transplant Hepatology Pilot Steering Committee collaborated to create a three-year combined GI/TH Training Pilot Program in 2012. In academic year (AY) 2014-2015, there were ten such pilot programs in the United States. Many of the positions in the Accreditation Council for Graduate Medical Education (ACGME)-accredited TH fellowship programs go unfilled annually [2].

However, the three-year combined GI/TH Training Pilot Program's impact on addressing this deficit is still unclear since its inception in 2012. To accurately design training pathways and estimate the ideal workforce, an updated workforce study is required. Numerous physicians begin their careers with significant debt. Many people believe that hepatologists make less money than their GI colleagues because TH is not primarily a procedural specialty. Although it has been demonstrated that decisions to avoid careers with lower earning potential, such as primary care specialties, the impact of debt on GI fellows' career paths has not been investigated. In addition, mentorship has been shown to have an impact on medical education across a variety of medical specialties and training levels. However, there is no existing body of research that looks into the role that a mentor plays in choosing GI subspecialty training. With regard to the reported career plans of GI fellows, our study aims to investigate the potential influencing factors for or against a career in hepatology, such as the impact of mentorship and educational debt [2].

Methods and Participants Survey Instruments the survey consists of a 35-item questionnaire (Supporting Appendix S1) designed to investigate: (1) respondent demographics; (2) characteristics of the training program; (3) factors that influence trainee decisions about pursuing hepatology as a career; and (4) mentor involvement in career decisions. Pilot testing by gastroenterologists from our respective institutions and members of the AASLD Transplant Hepatology Pilot Program Committee was used to design and evaluate this instrument. Distribution of the Survey an HTML link to the survey website and an introduction letter describing the Study were sent via email to GI program directors and trainees. The directors of the GI and TH programs were also asked to help recruit survey participants. To encourage completion, reminder emails were sent two and four weeks after the initial email. To increase study participation, the same survey was distributed in paper form at a nationally recognized GI board review course. Survey Monkey, a safe web-based application, was used for the survey's design and execution [3].

It is commonly believed that the increased length of training and financial barriers prevent GI fellows from pursuing careers in hepatology. The lack of transplant hepatologists and the declining number of transplant hepatologists taking the ABIM TH certification exam both point to the length of time required to become a hepatologist. Our research is the first to examine these factors. Familiarity with these elements might support changing how TH programs enroll GI colleagues and inside medication occupants. According to our findings, factors that are frequently cited as barriers to pursuing training in hepatology include the length of training, the additional application process, and the possibility of geographic relocation. This was especially true for people with families and women. University trainees are more comfortable with or more likely to see the value of additional training than those working or training at a community-based center, as evidenced by the fact that those working or training at a community-based center were more likely than those at a university center to list the additional year of training as a deterrent. We think that raising awareness of the combined GI/TH pilot program, especially among community-based centers, might help alleviate some of these worries. Sadly, nearly a quarter of respondents were unaware of the GI/TH pilot fellowship.

This suggests that raising awareness of the pilot program is a crucial component in recruiting applicants for the TH fellowship. Both those who intend to pursue a career in hepatology and those who do not were frequently quoted as a factor that would discourage them from applying for a TH fellowship. The majority of GI fellows, regardless of whether they intend to specialize in hepatology in the future, are drawn to endoscopy and want to incorporate it into their future practice. In view of this, TH partnerships might consider accentuating and setting out open doors for endoscopic methods while enlisting GI colleagues [4].

According to our research, it may be less of a deterrent than previously thought that hepatologists perceive a lower income. A small percentage of respondents (44%) stated that they would not pursue additional hepatology training if they received less money than their GI counterparts. The decision to pursue hepatology was also unaffected by debt, with the exception of those with debts greater than $200,000.We blame the cost of an additional year of training for this. When compared to those who were undecided or did not intend to enter hepatology, those who planned to enter the field were significantly more likely to be drawn to the financial rewards of hepatology (56.0% versus 33.5%, P = 0.044).It's possible that hepatologists' financial compensation options are better explained to those interested in the field, which could increase recruitment.

The hypothesis that the majority of respondents are primarily discouraged by earning potential and financial inequality is refuted by these findings. Most of the time, the GI fellow experiences TH in an inpatient setting. This frequently includes a large number of complex, decompensated patients with a high mortality and morbidity rate. One study found that exposure to similarly ill patients on inpatient oncology rotations decreased internal medicine residents' interest in pursuing this field. Few respondents who planned to enter hepatology cited the patient population as a deterrent, but those who were unsure or did not plan to enter hepatology were more likely to cite it. Long-term relationships with patients are cited as an attractive factor by 81% of those unsure about entering hepatology, compared to 49% of those who do not intend to enter the field. The perception of hepatology as a practice may be improved by exposing GI fellows to outpatient hepatology rotations where they can participate in longitudinal care, long-term relationships, and interesting benign hepatology [5].

The challenges and increasing demands in academic medicine (aging population with more complex disease, highly competitive research, and less value on teaching in career assessment) have reduced the number and availability of mentors. In our study, most trainees who were either already in a hepatology fellowship or were planning one had a mentor. Mentoring is known to help with career selection, advancement, publication productivity, grant funding, and grant funding. This information highlights the likely effect of mentorship by hepatologists in expanding interest in TH. To foster a development environment, TH training programs might think about expanding formal mentorship programs, starting informal gatherings and journal clubs, and establishing awards for outstanding mentorship. Interestingly, a plan for a career in hepatology was correlated with the presence of a mentor, regardless of specialty. This suggests that the mentor's career path was not as important as the mentorship itself. There are a few limitations to our study.

Since it is not known whether all 441 GI fellows in the AY 2014–2015 received a survey, the response rate can only be estimated. Accepting each GI individual got the study, the reaction rate among email and board survey participant beneficiaries was 180/441 (40.8%). Because the survey is a descriptive study, we are only able to look at correlations and not causality. The results may have been biased because some respondents had completed fellowships, despite a reasonable overall response rate. Respondents may not have consistently interpreted the questions they were asked because they were not supervised while taking the surveys. Time constraints, incorrect email addresses, email forwarding to the "junk" folder, and lack of interest were some of the factors that prevented respondents from completing the survey.

Acknowledgement

None

Conflict of Interest

None

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