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MarsRover

Im Subspecialties

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Hey,

 

 Can anyone explain to me why hepatology isn't its own subspecialty. It seems to me there is a massive amount of content a person could know about the liver. However, it is only a fellowship option for a subspecialty of IM, gastro. Making it a subspecialty of a subspecialty if you will. 

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Probably just that there's so much from GI that you need to know first that it's hard to just jump straight into hepatology. Plus the endoscopy skills are crucial. You could have a special interest in hepatology within a GIM fellowship as another alternative.

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Hey,

 

 Can anyone explain to me why hepatology isn't its own subspecialty. It seems to me there is a massive amount of content a person could know about the liver. However, it is only a fellowship option for a subspecialty of IM, gastro. Making it a subspecialty of a subspecialty if you will. 

 

A strong knowledge of GI is required for hepatology and the reality is we don't need that many hepatologists and hepatology as a field is not an aggressively expanding field so it is unlikely to try to set itself up as its own sub-spec. It is in general a field that will probably get smaller as time goes on in Canada since Hep C now has a cure, alcoholism as a whole is on the decline and Hep B is vaccinated against. With the new drug epidemic things may see a small bump but I don't really see it as a field that is growing dramatically. 

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A strong knowledge of GI is required for hepatology and the reality is we don't need that many hepatologists and hepatology as a field is not an aggressively expanding field so it is unlikely to try to set itself up as its own sub-spec. It is in general a field that will probably get smaller as time goes on in Canada since Hep C now has a cure, alcoholism as a whole is on the decline and Hep B is vaccinated against. With the new drug epidemic things may see a small bump but I don't really see it as a field that is growing dramatically. 

 

I disagree on the growth of hepatology.

Yes, there is now a cure for hepatitis C, but other causes of cirrhosis are on the rise (NAFLD/NASH) and will occupy hepatologists (and future hepatologists) for quite a while.

https://www.ncbi.nlm.nih.gov/pubmed/26707365

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I was also operating under the assumption that they would cover the vast array of metabolic and other enzymatic functions the liver does. I mean it is the site of most drug breakdown, protein breakdown, fat assembly etc etc. They would know could know about the different genetic defects, damages etc. I guess some of those may end up getting looked at by clin pharm, nephro, and endo though. 

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It is in general a field that will probably get smaller as time goes on in Canada since Hep C now has a cure, alcoholism as a whole is on the decline and Hep B is vaccinated against. 

 

Except that while HCV treatment used to be relatively simple (relatively), it's now become quite complex and not at all straightforward. "Cure" doesn't mean "gone" and we're still relatively early in this new treatment paradigm. 

 

I was also operating under the assumption that they would cover the vast array of metabolic and other enzymatic functions the liver does. I mean it is the site of most drug breakdown, protein breakdown, fat assembly etc etc. They would know could know about the different genetic defects, damages etc. I guess some of those may end up getting looked at by clin pharm, nephro, and endo though. 

 

 

Hepatologists don't deal with a lot of metabolic diseases, often because these manifest in children (or infants!) and because they often fall within other areas too. Another unique aspect of liver disease is that the "end-stage" is more or less uniform, i.e. cirrhosis, which is treated the same regardless of etiology. You'll still have your mainstay of autoimmune (AIH, PBC, PSC), viral, alcoholic, toxic, and metabolic liver disease, to say nothing of dealing with complications like variceal bleeds and decompensated cirrhosis. Lots of these things don't require specific hepatology training, but I don't know that I'd say that liver disease is becoming less of a problem. 

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A strong knowledge of GI is required for hepatology and the reality is we don't need that many hepatologists and hepatology as a field is not an aggressively expanding field so it is unlikely to try to set itself up as its own sub-spec. It is in general a field that will probably get smaller as time goes on in Canada since Hep C now has a cure, alcoholism as a whole is on the decline and Hep B is vaccinated against. With the new drug epidemic things may see a small bump but I don't really see it as a field that is growing dramatically. 

 

I would disagree. Where did you see those statistics? If anything, alcoholism has not changed over the years. Yes maybe more people now know that excessive alcohol is bad (and alcohol may be bad in certain instances of life like pregnancy) and can lead to liver disease and cirrhosis, however that doesn't change the fact that many people still cope with alcohol and develop addictions. It's still a 'legal' drug, easily accessible and cheap, and has been for several decades. A large number of patients I see have cirrhosis secondary to alcohol abuse.

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I would disagree. Where did you see those statistics? If anything, alcoholism has not changed over the years. Yes maybe more people now know that excessive alcohol is bad (and alcohol may be bad in certain instances of life like pregnancy) and can lead to liver disease and cirrhosis, however that doesn't change the fact that many people still cope with alcohol and develop addictions. It's still a 'legal' drug, easily accessible and cheap, and has been for several decades. A large number of patients I see have cirrhosis secondary to alcohol abuse.

 

http://onlinelibrary.wiley.com/doi/10.1002/cld.168/full

 

Smoking, Alcohol abuse are trending downwards nowadays, particularly among youth. 

 

One of the staff I've worked with told us something important, as doctors we see the bad cases. Only 20% of heavy 30+ pack year smokers actually end up developing COPD. Yes, probably over 90% of COPDers are smokers. Because of that if you spend time on the wards you'd think that most smokers get COPD. I think a lot of us were actually shocked that the number was only 20%. I would have thought it would be close to 40-50%. 

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http://onlinelibrary.wiley.com/doi/10.1002/cld.168/full

 

Smoking, Alcohol abuse are trending downwards nowadays, particularly among youth. 

 

One of the staff I've worked with told us something important, as doctors we see the bad cases. Only 20% of heavy 30+ pack year smokers actually end up developing COPD. Yes, probably over 90% of COPDers are smokers. Because of that if you spend time on the wards you'd think that most smokers get COPD. I think a lot of us were actually shocked that the number was only 20%. I would have thought it would be close to 40-50%. 

 

hah and after finishing a CTU rotation you begin to think of all elderly patients as quite sickly and bed-ridden. its amazing if you get to see some of your patients after in outpatient clinic. difference is night and day. we are certainly biased on inpatient rotations insofar as the patient populations we work with are simply quite sick.

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http://onlinelibrary.wiley.com/doi/10.1002/cld.168/full

 

Smoking, Alcohol abuse are trending downwards nowadays, particularly among youth. 

 

One of the staff I've worked with told us something important, as doctors we see the bad cases. Only 20% of heavy 30+ pack year smokers actually end up developing COPD. Yes, probably over 90% of COPDers are smokers. Because of that if you spend time on the wards you'd think that most smokers get COPD. I think a lot of us were actually shocked that the number was only 20%. I would have thought it would be close to 40-50%. 

 

I'm well aware of those statistics and I know that what you see at a tertiary centre is skewed. A previous poster was questioning how hepatologists can still stay in business because "alcoholism is on the down trend", and I was just pointing out my clinical experiences on several months of CTU, consult medicine and ICU that there is no shortage of patients with cirrhosis. I'd also like to believe it is centre-dependent, based on my experiences of doing med school and residency in two different cities, as well as having done electives in other cities. Certain cities see unique populations and demographics. 

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