How to Close the Gap Between the Numbers of Patients Who Need Liver Care and the Providers Available 

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By Arun J. Sanyal, MD, AASLD President

Chronic viral hepatitis affects one out of 50 people in the general population while nonalcoholic steatohepatitis affects one out of every 20 to 30 individuals. There are thus millions of Americans with chronic liver disease which remains clinically silent until advanced liver disease sets in. On the other hand, there are only a thousand or so fully trained hepatologists to serve our communities. This gap between the need for liver-related health care and the availability of trained manpower is dramatically underscored by a recent AASLD-sponsored survey which showed that there are 24 individuals currently in training as transplant hepatologists in ACGME-approved programs. A recent report from the Institute of Medicine further noted a marked lack of awareness, knowledge, and skills amongst the general medical workforce with regards to liver disease. If progress is to be made in eradication of liver disease and promotion of liver wellness, fixing this manpower shortage must become a national priority.

The current training pathway for hepatology requires sequential training in internal medicine, gastroenterology, and then hepatology. This arduous training pathway towards becoming a hepatologist is one reason for the current shortage of hepatologists. Even if the plans for shortening the training pathway for hepatology being designed by a multi-society task force are implemented, the projected maximum number of hepatologists being produced each year would vary from 50 to 150. This makes it exceedingly unlikely that the current gap between the need for health care providers well trained in hepatology and the availability of such individuals will be met any time soon using the traditional training pathways.

It is imperative that alternate solutions be sought. However, before engaging in that discussion, it is important to reiterate one cannot abandon the traditional training pathways in hepatology because it produces health care providers who can recognize and take care of complex liver diseases, manage end stage liver disease and its complications and the patient who requires liver transplantation. Indeed many centers are having difficulty in filling positions to take care of patients with advanced and complicated liver diseases. Therefore, any solutions must be in addition to, rather than instead of, existing approaches to training.

A Different Kind of Liver Provider (the case for primary care hepatology)
Recently, several centers have started providing high quality hepatitis treatment in a primary care setting (McGinn et al, Arch Intern Med, 2008, 168:2009-13). This raises the attractive possibility of providing hepatology services at the primary point of care. Thus, it is time to consider an alternate paradigm for hepatology, i.e. an ambulatory primary care hepatology training pathway which could involve six to twelve months of outpatient training in hepatology with a primary focus on viral hepatitis, nonalcoholic steatohepatitis and metabolic syndrome, and alcohol-related disorders. Such training could be imparted to primary care physicians or mid level providers in a relatively short period of time or even within the course of internal medicine training. While it is too early to talk more about such a concept, AASLD remains committed to exploring this and other potential ways to increase the workforce that is both trained in liver diseases and can see the clinically silent but afflicted individuals at their point of primary care in their community.

A Burden Too Large for Us Alone
Because chronic liver disease is frequently present in relatively asymptomatic individuals who only see primary care providers in their communities, there is a huge opportunity for intervention. AASLD is committed to the development of a multi-pronged strategy to increase the knowledge, attitude, and practice of hepatology by such providers: 
• It has recently engaged with the Centers for Disease Control to discuss development of educational materials for family practitioners, internists, gynecologists who also provide primary care, and mid level providers. The hepatitis B Special Interest Group (SIG) has already begun to develop such a module. AASLD will also look to partner with the Boards serving primary care specialties to develop practice improvement modules to enhance both the awareness of liver disease and their ability to recognize and initiate therapies.  Some of these efforts may translate in to educational materials that will benefit physicians and health care providers in parts of the world where resources are scarce.  Thus, it is likely that the impact of these efforts will be global.
• The treatment of liver diseases, particularly viral hepatitis, is highly nuanced. It is important to make sure that those engaged in the treatment of infected patients are knowledgeable about these nuances. Via its efforts at Digestive Disease Week and other educational fora, AASLD will continue to provide education to gastroenterologists, mid-level providers, and hepatologists to enhance their effectiveness. AASLD will also engage other societies involved in the care of hepatitis virus infected individuals or diabetics to extend the education related to viral hepatitis and NASH respectively.
• Training in liver diseases is a small component of the medical school curriculum in most medical schools, and internal medicine residency curricula also only have a limited amount of information on liver diseases. It is important to recognize that the training process should start early in a physician’s professional life. We need to explore opportunities in medical school and residency education to align the emphasis in training proportionately to the kind of diseases in the general population. 

This electronic newsletter is a bi-weekly publication of AASLD and replaces the former bi-monthly print newsletter and weekly e-news. Members are welcome to submit articles and may send suggestions to aharan@aasld.org.