HEPATOLOGY, Vol. 62, No. 2, 2015

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A Call to Action: The Need for Hepatology-Focused Educational Interventions in Internal Medicine Residency Training To the Editor: The prevalence of chronic liver disease (CLD) is steadily increasing in the United States. Despite increasing disease burdens, there is a significant shortage of hepatologists (1800) in practice.1,2 This stark imbalance highlights the critical need for Internal Medicine (IM) physicians to competently care for CLD patients. The IM Residency Program at the University of Chicago, which historically has only offered elective consult rotations in gastroenterology and hepatology, sought to assess its graduating postgraduate year-3 (PGY-3) IM residents’ knowledge of and comfort with the management of CLD. A paper-based anonymous survey was distributed to 27 PGY-3 IM residents. The assessment included 12 standardized multiple-choice questions from the Medical Knowledge Self-Assessment Program 15 and the Digestive Diseases Self-Education Program and 25 items which assessed self-efficacy and preparedness to manage CLD using Likert scales. Additionally,

Fig. 1. (A) The percentage of residents who were comfortable managing each topic surveyed. (B) The percentage of residents who answered each hepatology-related question correctly. Abbreviations: LFT, liver function test; HCV, hepatitis C virus.

deidentified American College of Physicians IM In-Training Examination data from 2011 to 2013 were analyzed. The residents overwhelmingly agreed that gastroenterology and hepatology were integral to IM training; however, despite seven opportunities to do so, 44.4% did not elect to rotate on either of these consult services during residency. All of the PGY-3 residents agreed that they were comfortable managing certain common general medicine and cardiology conditions (Fig. 1A). However, only a minority were comfortable managing common hepatologic diseases (e.g., hepatitis B and C, nonalcoholic steatohepatitis, cirrhosis, hepatorenal syndrome, and acute liver failure). Interestingly, they were more comfortable with topics that frequently overlap with other IM rotations (e.g., spontaneous bacterial peritonitis, performing a paracentesis, and abnormal liver function tests). Overall, the residents performed poorly on the objective assessment of CLD knowledge; the mean percentage of correct answers was only 56.5% (Fig. 1B). Only 37% of the residents elected to rotate on the hepatology consult service during their residency;

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these individuals scored slightly higher (60%) than those who did not (54.4%). Furthermore, the mean percentage of hepatology questions answered correctly on the In-Training Examination by the resident cohort of this study was 71% in PGY-1, which downtrended to 63% in PGY-3. A similar trend was observed nationally as well. These data strikingly demonstrate that many graduating PGY-3 residents do not have a strong understanding of CLD and that postgraduate hepatology-focused educational interventions are needed. Furthermore, despite overwhelming agreement that the gastroenterology and hepatology services are integral components of IM, many have never rotated on either. This suggests that the traditional learner-centric system, which allows trainees to electively choose specialty rotations, may be contributing to inadequate education in specialty topics, including hepatology. In response to these data, our IM Residency Program has established a nonelective liver rotation that 26 categorical residents will rotate on each year. The educational strategies employed on this service, including mandated modules in the ACT-First Hepatitis B and C curriculums in LiverLearning of the American Association for the Study of Liver Diseases, are now being studied to assess for improved understanding of CLD among residents. ADAM E. MIKOLAJCZYK, M.D.1 ANDREW A. ARONSOHN, M.D.1,2

JOHN F. MCCONVILLE, M.D.1 DONALD M. JENSEN, M.D.1,2 JEANNE M. FARNAN, M.D., M.H.P.E.1 1 Department of Medicine The University of Chicago Medicine Chicago, IL 2 Center for Liver Diseases Section of Gastroenterology Hepatology, and Nutrition The University of Chicago Medicine Chicago, IL

References 1. Luxon BA. So you want to be a hepatologist? Gastroenterology 2013; 145(6):1182-1185. 2. Kottilil S, Wright M, Polis MA. Treatment of hepatitis C virus infection: is it time for the internist to take the reins? Ann Intern Med 2014;161(6):443-444. C 2015 by the American Association for the Study of Liver Diseases. Copyright V View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.27591 Potential conflict of interest: Nothing to report.

Difference in Budd-Chiari Syndrome Between the West and China DAIMING FAN, M.D., PH.D.2 Department of Gastroenterology General Hospital of Shenyang Military Area Shenyang, China 2 Xijing Hospital of Digestive Diseases Fourth Military Medical University Xi’an, China

To the Editor:

1

We read with great interest the review by Wang and colleagues1 that comprehensively analyzed the similarity and discrepancy in the epidemiology and characteristics of liver diseases between China and Western countries. Several common liver diseases were discussed, such as viral hepatitis, alcoholic liver disease, nonalcoholic fatty liver diseases, liver cirrhosis, and hepatocellular carcinoma. Herein, we express additional concern about Budd-Chiari syndrome (BCS) which is a vascular liver disease resulting in life-threatening liver failure and portal hypertension–related complications.2 The sites of occlusion, clinical presentations, etiological distributions, and preferred treatment modalities of BCS may be different between Western and Chinese populations. First, the occlusion is often located at the hepatic veins in the West. By comparison, a combined occlusion of hepatic vein and inferior vena cava is the most frequent type of BCS in China. Second, most Western patients have a rapid disease course with progressive hepatic function impairment due to acute thrombosis within the hepatic veins. However, a majority of Chinese patients have a relatively long history of abdominal wall varices and lower limb edema due to chronic occlusion of the inferior vena cava.3 Third, approximately 80% of Western patients have at least one thrombotic risk factor,4 such as myeloproliferative neoplasms with or without JAK2 V617F mutation, factor V Leiden mutation, prothrombin G20210A mutation, and paroxysmal nocturnal hemoglobinuria. In contrast, these are less frequently observed in Chinese patients.5,6 Fourth, anticoagulation and transjugular intrahepatic portosystemic shunt are the mainstay treatment options for Western patients. On the contrary, our recent survey of 23,352 Chinese BCS patients suggests that percutaneous recanalization is the most common treatment modality.7 This is because percutaneous recanalization alone can achieve an excellent long-term patency and survival in most Chinese BCS patients. Collectively, the difference in the characteristics of BCS between the West and China should be clearly recognized by Chinese hepatologists. XINGSHUN QI, M.D.1,2 XIAOZHONG GUO, M.D., PH.D.1

References 1. Wang FS, Fan JG, Zhang Z, Gao B, Wang HY. The global burden of liver disease: the major impact of China. HEPATOLOGY 2014;60:2099-2108. 2. DeLeve LD, Valla DC, Garcia-Tsao G. Vascular disorders of the liver. HEPATOLOGY 2009;49:1729-1764. 3. Qi X, Han G. Abdominal-wall varices in the Budd-Chiari syndrome. N Engl J Med 2014;370:1829. 4. Darwish Murad S, Plessier A, Hernandez-Guerra M, Fabris F, Eapen CE, Bahr MJ, et al. Etiology, management, and outcome of the BuddChiari syndrome. Ann Intern Med 2009;151:167-175. 5. Qi X, Wu F, Ren W, He C, Yin Z, Niu J, et al. Thrombotic risk factors in Chinese Budd-Chiari syndrome patients. An observational study with a systematic review of the literature. Thromb Haemost 2013;109:878-884. 6. Wang H, Sun G, Zhang P, Zhang J, Gui E, Zu M, et al. JAK2 V617F mutation and 46/1 haplotype in Chinese Budd-Chiari syndrome patients. J Gastroenterol Hepatol 2014;29:208-214. 7. Qi XS, Ren WR, Fan DM, Han GH. Selection of treatment modalities for Budd-Chiari syndrome in China: a preliminary survey of published literature. World J Gastroenterol 2014;20:10628-10636.

Author names in bold designate shared co-first authorship. C 2015 by the American Association for the Study of Liver Diseases. Copyright V View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.27628 Potential conflict of interest: Nothing to report.

A call to action: The need for hepatology-focused educational interventions in Internal Medicine Residency training.

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