Hepatology Elective
James A. Haley VA Hospital
Goals and Objectives
Medical Knowledge:
Gastroenterology fellows completing this rotation will have an in depth knowledge of the
following:
1. Epidemiology, pathophysiology, and clinical presentation of hepatitis A, C and B.
2. Pathophysiology and clinical manifestations of autoimmune liver disorders
including autoimmune hepatitis, PBC, and primary sclerosing cholangitis.
3. Pathophysiology and clinical manifestations of alcoholic liver disease including
alcoholic hepatitis and cirrhosis.
4. Pathophysiology and clinical manifestations of NASH.
5. Pathophysiology and clinical manifestations of portal hypertension, hepatic
encephalopathy, and hepato-renal syndrome
6. Pathophysiology and clinical manifestations of genetic disorders effecting the
liver.
7. Pathophysiology and clinical manifestations of fulminant liver failure.
8. Indications for liver transplantation.
9. Ability to calculate a MELD score.
10. Laboratory evaluation of liver disorders.
11. Indications for liver biopsy, hepatic angiography, hepatic imaging procedures,
and TIPS.
Patient Care:
Gastroenterology fellows completing this rotation will be able to evaluate, diagnose and
manage the following conditions:
1. Hepatitis A, B and C, autoimmune liver disorders, alcoholic liver disease, NASH,
and genetic liver disorders (hemochromatosis, Wilson’s disease, alpha1 antitrypsin deficiency, and others).
2. Complications of cirrhosis including esophageal varicies, ascites, spontaneous
bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome.
3. An understanding and ability to apply the methods employed to assess quality of
care and initiate improvement projects in patients with liver disorders.
4. A commitment to continuous improvement in the delivery of medical care
including the appropriate use of liver transplantation.
5. The ability to evaluate reported hepatic and related research, and use the
information obtained from reviewing the literature to improve the care of patients
with liver disorders.
6. The ability to use information technology to manage practice information.
7. The ability to use information technology to enhance professional development
and continuing education.
8. The ability to institute preventative measures in patients with liver disorders
including hepatitis A and B vaccination, other appropriate adult vaccinations, and
prophylactic use of antibiotics in cirrhotics with GI bleeding and patients with a
history of SBP.
9. The ability to screen for hepatoma in appropriate patients.
10. A willingness to participate in the education of students, residents and other
health care professionals.
Practice Based Learning and Improvement:
Gastroenterology fellows participating in this elective rotation will develop:
1. A critical approach to the hepatology literature to facilitate review and
assessment of the quality of reported scientific studies.
2. An ability to apply the methods used to assess quality of care and initiate
quality improvement projects for patients with liver disorders..
3. A commitment to continous quality improvement in the delivery of care to
patients with liver disorders.
4. The ability to evaluate reported research and use the information obtained from
reviewing the literature to improve patient care.
4. The capability of using information technology to manage data on patients
with liver disorders.
5. The ability to use information technology to enhance professional development
and continuing education.
6. A willingness to participate in the education of students, residents and other
health care professionals involved in the care of patients with liver disorders.
Systems Based Practice:
Gastroenterology fellows participating in this elective rotation will:
1. Be able to function as part of the liver transplant team.
2. Understand and be able to participate in liver transplant committee meetings.
3. Be able to function as a patient advocate for individuals with advanced liver
disease.
4. Be able to participate in the multidisciplinary management of patients with
hepatocellular carcinoma.
Communication:
Gastroenterology fellows participating in this elective rotation will be able to:
1. Create and sustain a therapeutic and ethically sound relationship with patients
having advanced liver disease, and with their families.
2. Communicate effectively with chronically ill patients and their families.
3. Work with others as an effective team member.
4. Counsel and educate patients and families concerning health issues relating to
liver disease, transplantation, and expectations post treatment and
transplantation.
Professionalism:
Gastroenterology fellows participating in this rotation will learn and/or demonstrate:
1. Respect, compassion and integrity in all interpersonal relationships.
2. A commitment to provide continued effort until patient care needs are
completed or responsibility for them is transferred to another health care
provider.
3. An understanding of diversity issues treating all patients with respect and
consideration.
4. A commitment to the ethical principles pertaining to informed consent.
5. Accountability to patients, society and the profession.
6. A commitment to lifelong learning and continued professional development.
Upon successful completion of this elective, the fellow may expect to achieve an
acceptable level of competence in the management of common and uncommon disorders
of the liver, and the management of patients with end stage liver disease. In addition,
there will be exposure to the selection and management of liver transplant patients. This
will involve the interpretation of symptoms and physical findings, utilization of
appropriate laboratory and radiological investigations, and review of pathologic material.
This will be achieved through a combination of direct patient contact and personal
instruction. Patients are seen at the James A. Haley VA Hospital inpatient and outpatient
services.
Patients seen run the gamut of liver ailments, including viral hepatitis, NASH, alcoholic liver
disease, PBC, PSC, autoimmune hepatitis, cirrhosis, and pre- and post transplant patients.
There is a significant amount of hepatitis C, but not so much as to preclude seeing other
conditions. HCV patients include those currently on treatment, newly diagnosed patients, and
those that have failed treatment, or are unable to receive treatment due to comorbidities.
After completion of the elective, a fellow should have confidence in diagnosing and
treating common and uncommon liver ailments, and should be able to realize when they need
further referral, especially for transplantation.
Evaluation:
Appropriate formative feedback will be provided to the fellow throughout the rotation by the
hepatology attending. The gastroenterology fellow will be evaluated at the conclusion of the
rotation by the hepatology attending at the VA Hospital. Evaluation will be based on
observation of the resident during rounds, procedures and conferences. Skills will also be
assessed by observation of the resident while taking histories, performing physical
examinations, and communicating with patients and families
Hepatology Rotation James A. Haley VA Hospital
Knowledge, Skills and Attitudes
Year Two
Knowledge
An understanding of the pathophysiology of liver disorders
A knowledge of the manifestations and treatment of common liver disorders
A knowledge of the indications for and side effects of anti-viral therapy for
hepatitis B and C
A knowledge of the health maintenance measures needed in patients with liver
disorders
A knowledge of the screening criteria for hepatoma in patients with liver disease
Skills
The ability to assess liver size on physical examination
The ability to detect signs of advanced liver disease
The ability to perform a liver biopsy
The ability to treat variceal bleeding with medical and endoscopic therapy
The ability to initiate and conduct therapy of hepatitis B and C with anti-viral
therapy
Attitudes:
Open to lifelong learning
Willingness to provide long term care for chronic illnesses
Willingness to be a patient advocate
Places an emphasis on prevention and screening
Year Three:
Knowledge:
An understanding of the manifestations of uncommon liver disorders
A knowledge of the indications for liver transplantation
A knowledge of the manifestations and causes of post liver transplant disorders
A knowledge of the indications for use of immunosuppressive drugs in the
treatment of liver disorders, and management of post transplant patients
Skills:
Ability to calculate a MELD score
Ability to diagnose and treat the cause of liver dysfunction after liver transplant
Ability to regulate immunosuppressive medications in patients post liver
transplant and those with autoimmune liver disorders
Ability to recognize and treat uncommon liver disorders
Attitudes:
Lifelong learning
Patient advocacy
Commitment to providing long term care for patients with chronic illnesses
Willingness to work with a team to provide care for patients with chronic disease