The Role Of A Hepatologist:
Hepatology is a recognised subspecialty of gastroenterology. Hepatologists specialise in diagnosing and treating liver pathologies and may also treat pathologies of the biliary duct.
Some of the conditions hepatologists work with are cirrhosis, acute and chronic liver failure, vascular liver disease, malignant and benign tumours of the liver, cholangiocarcinoma (bile duct tumour), Hepatitis B and C, and many others.(1)
Hepatologists therefore learn and perform practical procedures that are most often, though not exclusively, performed on patients with liver pathologies. These include different types of liver biopsies, measuring portal pressure, ultrasound and ultrasound guided liver biopsy, endoscopic ultrasound, and more.(1)
Not only hepatologists, but all gastroenterologists should understand and recognise the indications for liver transplantation, as well as its limitations, and be able to determine which patients would most benefit from the procedure.(1) Deciding whether liver transplantation is necessary, conducting the follow-up treatment and performing liver function tests is an important part of a hepatologist’s job.
Hepatologists may work in the intensive care unit (ICU) or high dependency unit (HDU) and offer specialist liver clinics, work in a liver specialist ICU, or in level 2 or 3 specialist centres.(1) Level 2 offers a range of services to treat liver disease aside from transplantation, and level 3 centres are those that include liver transplantation units.(2)
Hepatologists work with gastroenterologists and doctors in other specialties, specialist nurses, surgeons, pathologists, oncologists, radiologists, administrative staff, and research teams.(3)
In 2018, 77% of gastroenterologists and hepatologists were male, and only 23% female, however the number of women in higher specialty training in gastroenterology and hepatology is increasing.(4)
Hepatology is a rapidly expanding field and is slowly starting to be recognised as a stand-alone specialty.(5) It is a relatively new but fast-evolving field, and hepatology specialists are becoming increasingly more valued in hospital teams and ICUs.
Arguably the situation has improved since 2011 when many consultant hepatologists and gastroenterologists told a survey that training programmes for liver disease management should be improved.(5)
A Typical Week:
Hepatologists divide their time between carrying out specialist clinics, conducting ward rounds, managing patients in the ICU and admitting new patients, performing practical procedures such as endoscopies, and doing administrative work.(1,3)
Most gastroenterologists and hepatologists work on-call rotas, but fewer than 60% of consultants are regularly on-call during weekends.(3) Those hepatology and gastroenterology consultants who obtained a qualification in general internal medicine as part of their CCT will also participate in GIM on-call rotas.(1)
There are plenty of research opportunities in hepatology, and many hepatologists participate in clinical trials. The research and trials are aimed to find new methods and improve old methods for detection, treatment and prevention of liver disease.(6)
Hepatology consultants can carry out research and take part in clinical trials alongside their clinical careers. Hepatology trainees will acquire research competencies as a part of their trainings, but they can also take time out of the programme to conduct a research project if they wish.(1)
The Route To Becoming A Hepatologist:
Since hepatology is a CCT sub-specialty in gastroenterology, trainees wanting to specialise in hepatology have to first complete core medical training and the first 2 or 3 years (depending on whether they opt to train in general internal medicine as well) of gastroenterology higher specialty training.(1)
Hepatology trainees will begin their hepatology part of the programme in the second-last year of their higher specialty training, and they must spend a total of two years training in liver disease.(1)
To enter core medical training, applicants must have obtained a medical degree, and completed the 2-year UK foundation training programme or equivalent.(1) Core training can be taken via one of two pathways: 2-year core medical training (CMT) programme, or 3-year acute care common stem (ACCS) programme. Core training consists of four to six placements, which must include working directly in acute medicine.(1)
After the successful completion of core training, and after they have passed the Membership of the Royal College of Physicians (MRCP) UK exam, trainees wanting to specialise in hepatology must then enrol into ST3 in gastroenterology.(1) Trainees who wish to obtain a dual CCT in gastroenterology/hepatology and general internal medicine will have to apply to programmes which are openly advertised as dual training programmes.
The core training and higher specialty training will last 4 or 5 years overall, depending whether it is purely in gastroenterology/hepatology or whether it involves training in GIM.(1)
Out of the 4 or 5 years of training, a total of 2 years must be spent training in liver disease for a trainee to specialise in hepatology. Hepatology subspecialty training is usually entered in ST5.(1) At least 12 months of hepatology training will be spent at a designated teaching hospital and, if possible, all training should be spent at level 2 and level 3 liver specialist centres, while one whole year must be spent at a level 3 specialist centre (which offers liver transplant services).(1,2) If this is impossible, up to 6 months can be spent at a level 1 centre (only offers a standard hepatology clinic).(1,2)
To complete the hepatology training, a trainee must pass the Examination in Gastroenterology and Hepatology (ESEGH) (previously known as Specialty Certificate Exam).(1) There will also be ongoing assessment throughout the training, as well as other certificates, e.g. Advanced Life Support Certificate or certificate for successful training in Ionisation Radiology (Medical Exposure) Regulations.(1)
The competition ratio for ST3 entry into gastroenterology in 2019 was 2.97 applicants per post, and when applying for a hepatology module, candidates apply in open competition for a training post or they can be interviewed for a higher clinician scientist post, usually at one of the level 3 specialist centres.(7)
Medical students who choose to work towards a career in hepatology should joint their university’s hepatology or gastroenterology society, or even a national specialist society as a student member (British Society of Gastroenterology), attend hepatology/gastroenterology focused conferences, choose a relevant supervised research project, and consider getting involved with the GMC and BMA.(8)
Foundation trainees aspiring to become hepatologists should use placements to experience the specialty, and other specialties they might be interested in, and should not only apply for rotations in gastro/hepatology but other related specialties such as GIM in case there are no vacancies.(8)
They should also ask qualified specialists for their experience in gastro/hepatology, take part clinical audit and look for teaching and management opportunities, and ensure their ePortfolio is up to date.(8)
Core and specialty trainees on their way to becoming hepatologists should ensure they have sound knowledge of acute general medicine, try out the taster membership in the British Society of Gastroenterology, and conduct their own research about the specialty.(8)
It is also beneficial for trainees to undertake research projects related to the specialty and attempt to get published or present their work at conferences.(8) Trainees should look for teaching and leadership possibilities where possible.(8)
There are 7 liver transplant centres in the UK: Royal Free Hospital and King's College Hospital, in London; Queen Elizabeth Hospital, Birmingham; St James's University Hospital, Leeds; The Freeman Hospital, Newcastle; Addenbrooke's Hospital, Cambridge and the Edinburgh Royal Infirmary.
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020 the salary bands range from £77,779 to £109,849. Salaries can be further enhanced with NHS excellence awards.
In 2008, the ratio of NHS income to private income for gastroenterology consultants was 0.60.(9) A consultant’s pay will increase with increasing experience and more time spent in consultancy, and there are also opportunities for pay increase via acquiring different awards or allowances, e.g. Clinical Excellence awards or distinction awards.(10)
For more information on salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
Both prospective and current hepatology trainees should ensure they have sufficient knowledge of the specialty and its requirements. Websites like the British Liver Trust, European Association of the Study of Liver (EASL), British Society of Gastroenterology, or the GMC will be useful while conducting research about the specialty. EASL also publishes the Journal of Hepatology, which contains the latest advances in hepatology as both an academic and a clinical specialty.
Other forms of resources are also available, such as the Lancet Gastroenterology & Hepatology podcasts, and a variety of textbooks for all areas of gastroenterology and hepatology.
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Joint Royal College of Physicians Training Board, Sub-specialty training curriculum for Hepatology, pdf, published Aug 2010, amended Aug 2013, https://www.jrcptb.org.uk/sites/default/files/2010%20Hepatology%20Curriculum%20%28amendments%202013%29%20V2.pdf, (accessed Sep 2020)
R Scott, M Williams, A Lawson, et al, Service provision for liver disease in the UK: a national questionnaire-based survey, published Apr 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4954093/, (accessed Sep 2020)
NHS health careers, Working life- gastroenterology, https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/gastroenterology/working-life, (accessed Sep 2020)
C. Rutter, British Society of Gastroenterology, Workforce report 2018, published Oct 2018, updated Apr 2020, https://www.bsg.org.uk/wp-content/uploads/2020/02/British-Society-of-Gastroenterology-Workforce-Report-2019-.pdf, (accessed Sep 2020)
I Patanwala, A Heycock, M Hudson, British Association for the Study of the Liver, The current state of hepatology training in the UK- results from a national trainee survey, published Mar 2011, https://gut.bmj.com/content/60/Suppl_1/A15, (accessed Sep 2020)
British Liver Trust, Research and clinical trials, https://britishlivertrust.org.uk/health-professionals/research-and-clinical-trials/, (accessed Sep 2020)
Health Education England, Specialty recruitment competition ratios 2019, pdf, https://specialtytraining.hee.nhs.uk/Portals/1/Competition%20Ratios%202019_1.pdf, (accessed Sep 2020)
NHS health careers, Training and development- gastroenterology, https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/gastroenterology/training-and-development (accessed Sep 2020)
Journal of the Royal Society of Medicine, Table 3- conditional mean income by specialty, pdf, published Jul 1 2008, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442143/table/tbl3/, (accessed Aug 2020)
NHS Employers, Pay and conditions circular MD 1/2017, pdf, published Mar 2018, https://www.nhsemployers.org/-/media/Employers/Documents/Pay-and-reward/Junior-Doctors/FINAL-Pay-and-Conditions-Circular-MD-12017-MARCH-2018.pdf, (accessed Sep 2020)