Hepatology

I. Goals and Objectives:

During this rotation, the PGY-2 will gain experience related to the evaluation and managmenet of all varieties of liver disease, complications of portal hypertension, as well as pre and post liver transplantation patient care (see below for specific areas to be addressed)

A. Overview:

The program of the hepatology/liver transplantation (discipline) is designed to provide the house officer with the knowledge and skills needed to diagnose and treat diseases of the liver.

Patients are very diverse ethnically and socioeconomically, and are representative of the neighboring Montefiore communities.

The rotation consists of one block of 4 weeks. The rotating house office is not on call for the rotation. 24/7 coverage is provided by the liver transplantation PA’s. The rotation is available to all Internal Medicine pgy2s.

Residents work in teams under the supervision of the GI and Hepatology fellows and the Medical Hepatology/Surigcal Liver Transplantation Attending. The Hepatology Attending physician is responsible for supervision of all patient care.

B. Level based Rotation Goals and Objectives:

PGY2:

- Patient Care: Prioritize the daily “work”; recognize the relative significance of a given patient’s list of conditions; begin to recognize the acuity levels of illness; understand the indications, contraindications and risks of procedures; work with all providers to provide patient focused care.

- Medical Knowledge: Use literature and reference sources to increase knowledge base; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of disease states; apply knowledge in the treatment of patients.

- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences.

- Interpersonal Skills: Write understandable and legible notes and consultation reports; improve ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team.

- Practice Based Learning and Improvement: Understand limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed. Do not overstep responsibilities.

- System Based Practice: Learn to be an advocate for patients; accept and try to apply necessary devised guidelines; to develop understanding about the health care systems/structure and how it relates to patients requiring procedures.

II. AREAS COVERED DURING the ROTATION

SPECIFIC PROGRAM CONTENT

Prevention, evaluation and management of acute and chronic end stage liver disease (includes genetic disorders involving the liver, alcoholic and non-alcoholic steatohepatitis)

Comprehensive management of critically ill patients awaiting transplant with complications including:

Refractory ascites

Hepatic hydrothorax

Hepato-renal syndrome

Hepatopulmonary and portal pulmonary syndromes

Refractory portal hypertensive bleeding

Diagnosis and management of hepatocellular carcinoma and cholangiocarcinoma including transplantation, non-transplantation, surgical and non-surgical approaches

Management of chronic viral hepatitis in the pre-, peri- and post-transplantation settings

Management of fulminant liver failure

Psychosocial evaluation of transplant candidates, in particular those with history of substance abuse

Transplant immunology including blood group matching, histocompatibility, tissue typing and malignant complications of immunosuppression

Drug hepatotoxicity

Interaction of drugs with the liver

Nutritional support of patients with liver disease

Use of interventional radiology in diagnosis and management of portal hypertension, as well as biliary and vascular complications

Ethical considerations relating to liver transplant donors

Indications, contraindications and complications of liver allograft biopsies

Appropriate use of ultrasound localized, laparoscopy-guided and transjugular liver biopsies

ROTATION DIDACTIC CONTENT

Pathogenesis, manifestations and complications of end-stage liver disease and hepatic transplantation

Appropriate use of laboratory tests and procedures

Anatomy, and physiology related to the liver and biliary tract

Pharmacology related to the liver and biliary tract

Pathology related to the liver and biliary tract

Molecular virology related to the liver and biliary tract

Natural history of chronic liver disease

Factors involved in nutrition and malnutrition and its management

Cost-effective use of special instruments, tests and therapy in the diagnosis and management of liver disorders

Principles and practice of pediatric liver transplantation

Principles and application of artificial liver support

Clinical research issues and transplant hepatology

Principles of living donor selection

III. SCHEDULE OF ACTIVITIES

1) Daily Morning rounds by Hepatology attending. These rounds include teaching sessions by the attending and the GI and Hepatology fellow. Distribution of literature.

2) Daily consultation rounds by attendings.

3) Division Grand Rounds Weekly

4) Pathology Rounds every other week

5) Literature review: Weekly

6) Liver Transplantation Selection Conference Weekly

7) Medical Grand Rounds – weekly

IV. RESPONSIBILITIES

• Weekday SICU patients – responsibility of Liver fellow (pre-op and post-op).

• Weekday MICU (generally acute liver failure) – responsibility of Housestaff (patients co-managed by ICU and liver)

• Weekday Foreman 7AE / Step Down Unit (SDU) patients – responsibility of Housestaff

• Weekend - all hepatology patients – responsibility of Housestaff (NOTE: if census exceeds 20 patients on the weekend, then priority should be for all Foreman 7AE SDU patients, as the MICU patients will have the ICU team writing notes on them).

• Discuss with attending who will follow/present on rounds/write notes on SICU patients on Sundays. (Housestaff can follow these patients on Sundays as the liver fellow will be off)

• Consults (wherever they are in the hospital) -- responsibility of Liver fellow

*Census should not go above 20 patients

*Transplant selection meetings occur at 3pm on Mondays in TLC 4 (across from the Cherkasky Auditorium where Grand Rounds takes place)—should try to go especially if your patients being presented or discussed.

Rounds

Generally, start at 9am in SICU (Foreman 3rd floor), followed by MICU and then the primary service rounds on Foreman 7AE in the conference room or in the back of the unit (attending dependent).

Weekends:

Saturdays are OFF for housestaff. For Sundays, coordinate with your attending as for the rounding time and where to meet. You will not be doing consults. There is no dedicated Liver fellow (only a covering Liver fellow from Weiler who is usually off doing procedures or consults) usually just you and attending so coordinate with them because time varies.

*No emergent paracentesis over weekend, but diagnostic should be done. If you are not certified call med consult.

V. EDUCATION MATERIALS

• Rotation specific orientation available on a PowerPoint. Please see below.

• The entire Hepatology/Liver transplantation curriculum is available online via the Montefiore Intranet.

VI. METHODS OF TEACHING COMPENCY ASSESSMENT

The house officers are evaluated continuously during their four weeks of service in the rotation. Importantly, there is continuous feedback to the house officers. The final evaluation is done through www.new-innov.com and the results are discussed in a meeting with the house officers. They are evaluated in terms of their overall clinical competence with the following categories: clinical judgment, medical knowledge, clinical skills, humanistic qualities, professionalism, medical care and continuing scholarships.