Transplant Hepatology / Training in Advanced Therapeutic Endoscopy

Overview and Objectives Clinical and Educational Activities Research Current Trainees Faculty Benefits Career Paths of Recent Graduates Contact Information and How to Apply

OVERVIEW AND OBJECTIVES

The fellowship training program in gastroenterology and hepatology at the University of Cincinnati was founded by Leon Schiff, one of the fathers of modern day hepatology. It is among the oldest GI fellowship programs in the United States and has a long and distinguished history of producing superbly trained specialists in digestive diseases.

Our Accreditation Council for Graduate Medical Education (ACGME)-accredited gastroenterology training program includes rotations under the guidance of full-time faculty from the University of Cincinnati College of Medicine at both the University Hospital (UH) and the Veterans Affairs Medical Center (VAMC). Both hospitals and the College of Medicine are located within a one block area.

UH serves as the principal city hospital and as a major academic referral center for the tri-state region (Ohio, Indiana, and Kentucky). The populations served by UH and VAMC provide the fellow with a broad exposure to a wide array of patients and illnesses, thereby assuring a diverse clinical experience.

The primary aim of the fellowship program is the training of gastroenterologists and hepatologists who will maintain life-long scholarly interests in the pathophysiology and treatment of gastrointestinal and hepatobiliary disorders. All fellows are expected to acquire clinical competence in all aspects of gastroenterology and hepatology, to develop facility in a range of endoscopic procedures, to provide high-quality compassionate and cost-effective care, and to engage in and conduct one or more research projects.

Fellows with an interest in academic gastroenterology, either in basic laboratory research or in clinical research as academic clinician-educators, are included within the structure of the fellowship program.

We have formulated a three-year curriculum that emphasizes the strengths of our faculty and patient populations. During the first two years of training fellows develop substantial experience in the clinical management and treatment of a wide spectrum of digestive diseases through direct interactions with inpatients and outpatients. This is accomplished through rotations on the following services:

• Gastroenterology and hepatology inpatient service;
• Hepatology consult service;
• VAMC gastroenterology/hepatology consult service;
• Manometry;
• Nutrition;
• Clinical research;
• Outpatient gastroenterology clinic; and
• Outpatient liver clinic.

The fellowship emphasizes an understanding of statistics, outcomes research, epidemiology and study design for all trainees. Time blocks dedicated primarily to research activities are present in both the basic science and clinical tracks.

During the third year, fellows have the opportunity to develop an area of clinical focus in therapeutic interventional endoscopy, liver disease, pancreaticobiliary disorders or nutrition.

In addition, there are additional training opportunities in transplant hepatology and advanced therapeutic endoscopy.

CLINICAL AND EDUCATIONAL ACTIVITIES

While on the different consultation services, the fellows work under the supervision of a staff attending, who is responsible for providing general guidance, teaching and direction. The consultation team also includes residents and medical students rotating on the service. Fellows are expected to actively participate in the training of these junior colleagues.

When rotating on the UH gastroenterology and hepatology inpatient service, fellows typically spend mornings performing endoscopic procedures and rounding with the service attending and medical team. In order to maintain continuity of care, the fellow will perform procedures on those patients admitted to the service. Fellows are expected to formulate diagnostic and treatment plans for patients and to assist with the supervision and teaching of the housestaff and medical students.

On the gastroenterology consult service, fellows generally spend mornings performing endoscopic procedures under faculty supervision. Procedures are performed on patients seen in consultation and those referred from the outpatient clinics. The GI endoscopy unit is staffed by full-time endoscopic nurses and other support personnel. An interventional endoscopy service, comprising an advanced therapeutic fellow and faculty, is responsible for advanced procedures such as ERCP and EUS. Consult service rounds generally occur in the afternoon. The fellows are expected to independently evaluate each consult, summarize the pertinent history and physical findings and formulate an appropriate diagnostic and therapeutic plan.

Through rotations on the UH liver consult service, the fellowship program provides intensive training in the evaluation and management of patients with hepatobiliary disorders. This includes recognition of the signs and symptoms of liver disease; the appropriate serologic, radiologic, and invasive workup for liver disease; the medical management of the patient with end-stage liver disease; and the indications/selection/timing for liver transplantation. Under the supervision of a faculty attending, the fellow participates in inpatient and outpatient liver consultations, performs all endoscopic procedures on liver patients and provides guidance to the housestaff in the management of inpatients. The fellow on the hepatology service also performs liver biopsies and reviews the histologic findings with the hepatology attending and hepatopathologist. TUH performs 40 to 50 liver transplants each year and the fellow, under the supervision of the hepatology attending, actively participates in the management of these patients.

Under the supervision of a faculty attending, the fellow participates in inpatient and outpatient liver consultations, performs all endoscopic procedures on liver patients and provides guidance to the house staff in the management of inpatients. Fellows on the hepatology service also perform liver biopsies and review the histologic findings with the hepatology attending and hepatopathologist. UH performs 40 to 50 liver transplants each year and fellows, under the supervision of the hepatology attending, actively participate in the management of these patients.

Rotations at the VAMC provide additional endoscopic experience and clinical training in gastroenterology, hepatology, pancreatic disorders, and pediatric gastroenterology.

Emergency consultations are answered by fellows (one fellow is on call every night for consults and emergency procedures). All emergency consultations and procedures are staffed by an attending.

Clinics
Clinic patients are assigned to specific fellows for one to three year periods to ensure continuity of care and exposure to longitudinal disease processes.

• Gastroenterology Clinics
  University Hospital gastroenterology clinic is supervised by Ralph Giannella, MD. Robert Weesner, MD supervises the VAMC gastroenterology clinic. Fellows are responsible for obtaining a clinical history, performing the physical examination and formulating an appropriate differential diagnosis and plan for evaluation and treatment. On average, 30 patients are evaluated in each GI clinic per week. The clinics are also attended by medical residents and students rotating on the GI service during that particular month. All cases are discussed with the attending physician.
• Hepatology Clinics
  The University Hospital liver clinic is supervised by the liver faculty on a rotating basis. The VAMC liver clinic is supervised by Nyingi Kemmer, MD. A weekly liver transplant clinic staffed by Guy Neff, MD and Nyingi Kemmer, MD, as well as the transplant surgeons, assesses patients with end-stage liver disease for transplantation and provides post-transplantation medical care.

Conferences
A variety of regularly scheduled conferences allow for the in-depth discussion of particular cases and topics; the exchange of ideas among internists, surgeons and pediatricians caring for patients with digestive diseases; and the presentation of scholarly information on clinical problems in gastroenterology. The regularly scheduled conferences include:

• GI Pathology Conference
  This is a monthly interdepartmental conference attended by members of pathology and the Division of Digestive Diseases. The conference provides an outstanding forum for correlating the clinical and pathologic aspects of gastrointestinal disease.
• GI/Surgical Conference
  This monthly conference is attended by members of the Department of Surgery and the Division of Digestive Diseases. Selected cases of mutual interest are presented by the GI fellows and surgical residents. After a brief presentation, the fellow or resident reviews the literature regarding the case and leads a discussion concerning the topic.
• Medical/Pediatric Clinical Conference
  This conference is held on a monthly basis in conjunction with faculty and fellows from the Division of Gastroenterology and Nutrition at Cincinnati Children's Hospital Medical Center (CCHMC). Selected cases are presented by adult and pediatric GI fellows, followed by a short discussion of the topic with group participation. This conference provides the GI fellow with exposure to the presentation and management of gastrointestinal diseases in pediatric populations.
• GI Physiology/Pathophysiology Conference
  This conference, which is held on a monthly basis, reviews GI physiology and pathophysiology and is presented by a fellow and a faculty mentor from the Division of Digestive Diseases and the Division of Pediatric Gastroenterology and Nutrition at CCHMC. Cases are provided as "unknowns" and discussed in the format of a CPC.
• GI Journal Club
  A monthly GI journal club reviews recently published articles of clinical relevance. Participants include GI faculty and fellows.
• Research Conference
  A research conference for faculty and fellows of the Division of Digestive Diseases is held monthly. Preliminary data from research-in-progress are presented by the GI faculty or fellows. Outside speakers with research interests in gastroenterology or hepatology also are invited to present.
• GI Summer Emergency Lecture Series
  For the first two months of the year, fellows receive weekly lectures on topics of general and immediate clinical relevance. Sample topics include introduction to gastrointestinal endoscopy, conscious sedation, gastrointestinal hemorrhage, fulminant hepatic failure and clinical study design.
• Clinical Topics Conference
  On a monthly basis, the GI faculty presents formal lectures on topics of clinical relevance within their areas of expertise to the fellows and rotating residents and students.
• Difficult Case Conference
  This "working conference" provides a format for the presentation and discussion of difficult diagnostic or management problems by faculty and fellows.
• Non-Traditional Curriculum
  The fellows meet with the GI training program director on a monthly basis to consider various programmatic issues. Outside speakers are invited to present non-traditional topics of interest to the trainees and to stimulate roundtable discussions. Sample topics include medical ethics, death and dying, disability insurance and asset protection, the impaired physician, coding and practice management, legal issues and risk management.
• Other Conferences
  Selected conferences throughout the year cover additional topics relevant to fellowship training, including GI radiology, nutrition, morbidity and mortality, and liver transplantation. Additional conferences are given by nationally recognized gastroenterologists and hepatologists on an ad hoc basis.

RESEARCH
Basic Research
Training in basic science research is available in the laboratories at the College of Medicine and the VAMC. Some of these include:

• Jason Blackard, PhD: Pathogenesis and the evolution of hepatitis viruses; HCV/HIV co-infection.
• M. Tarek Shata, MD, PhD: Immunological mechanisms of protection against viral infections, particularly hepatitis viruses (e.g., hepatitis B, hepatitis E).
• Kenneth E. Sherman, MD, PhD: Molecular characterization of hepatitis B & C, with specific focus on patients co-infected with HIV.
• Stephen D. Zucker, MD:Molecular mechanisms of cholestasis and hepatic metabolism.

The basic research interests of the division have focused on virology, membrane biology (particularly as it relates to transport phenomena), membrane receptors and receptor-signal transduction mechanisms. Most members of the division are using molecular biology, in combination with the classical approaches of biochemistry and physiology, to investigate these processes. Close collaborative relationships exist with the Division of Pediatric Gastroenterology and Nutrition at CCHMC and with the basic science departments at the university and the College of Medicine.

Clinical Research
For fellows envisioning a career as an academic clinician-educator, the goals of the fellowship include learning the fundamentals of clinical epidemiology and biostatistics and designing and conducting clinical research projects. All clinical fellows are expected to publish a review article and to conduct a clinical study during their tenure in the program. Fellows are also encouraged to take advantage of the opportunities for formal training in such courses as biostatistics and clinical epidemiology and to join fellows from other departments and divisions in developing the skills necessary to become a clinician-educator. Active programs in hepatic and pancreatic transplantation and advanced therapeutic endoscopy provide virtually unlimited opportunities for clinical studies.

Numerous members of the GI faculty are presently engaged in various clinical research projects and are available to work with and supervise the interested fellow. Additionally, gastrointestinal radiologists are active members of our training program and are available for collaboration and advice. Three gastrointestinal surgeons with active laboratory and research programs regularly participate in divisional activities and are also available.

CURRENT TRAINEES

Third Year Fellows 2009-2010

Curtis Barry, MD
Medical School: Boston University
Residency: Boston University

Ganesh Kakarlapudi, MD
Medical School: Creighton University
Residency: University of Cincinnati

Paul Schmeltzer, MD
Medical School: Georgetown University
Residency: University of Pittsburgh

Philippe Zamor, MD
Medical School: Boston University
Residency: Boston University

Second Year Fellow 2009-2010
Kashif Ahmed, MD
Medical School: Medical College of Georgia
Residency: University of Cincinnati

First Year Fellow 2009-2010
Christopher Albers, MD
Medical School: University of Cincinnati
Residency: University of Cincinnati

Justin Case, MD
Medical School: University of Cincinnati
Residency: University of Kentucky

Amy Dichiara, MD
Medical School: Emory University
Residency: University of Cincinnati

Halim Muslu, MD
Medical School: University of Istanbul (Turkey)
Residency: Tufts University

FACULTY
The administrative offices and research laboratories of the Division of Digestive Diseases are located on the sixth floor of the Medical Sciences Building. The Digestive Diseases Diagnostic and Treatment Center (DDC) is located on the second floor of University Hospital and is a part of a newly organized, multidisciplinary outpatient ambulatory center. The DDC includes a large reception area, seven procedure rooms, examination rooms, a fluoroscopy unit and a GI clinical laboratory.

All elective endoscopic, manometric and liver biopsy procedures are performed in the DDC. The facility has a complete range of fiber optic and video instruments for both upper and lower diagnostic and interventional (e.g., ERCP, EUS, laser coagulation) gastrointestinal procedures. It also utlizes a computer-generated reporting system. Endoscopists are assisted by trained nursing personnel and all procedures are staffed by the attending gastroenterologist. Safety standards are enhanced by utilization of electronic monitoring devices during procedures.

Following the endoscopic procedure, patients are monitored in a dedicated recovery area until they are ready for discharge. The GI fellowship trainee will therefore be exposed to a wide range of procedures in a state-of-the-art facility.

At the VAMC, the section of digestive diseases has recently renovated endoscopic, office and clinical study space on the fifth floor of the hospital. During each of their rotations, trainees work directly with our staff of experienced and nationally recognized clinicians:

Ralph A. Giannella, MD
Mark Brown Professor of Medicine
Gastroenterology/Diarrheal disorders

Sudip Ghosh, PhD
Gastrointestinal Motility

Norman Gilinsky, MD
Gastroenterology/Inflammatory bowel disease

Nyingi Kemmer, MD
Transplant Hepatology

Jonathan Kushner, MD
Director, University Hospital Endoscopy Unit
Gastroenterology/Nutrition

Guy Neff, MD
Medical Director, Liver Transplant Program
Transplant Hepatology

Nathan Schmulewitz, MD
Medical Director, Pancreas Center
Gastroenterology/EUS

Kenneth E. Sherman, MD, PhD
Division Director, Gould Professor of Medicine
Hepatology/Viral hepatitis

Robert Weesner, MD
Director, Gastroenterology, VAMC
Gastroenterology/Colorectal screening

Stephen D. Zucker, MD
Director, Gastroenterology Training Program
Hepatology/Cholestatic liver disease

BENEFITS

You may find benefit information on the web site for the Health Alliance Office of Graduate Medical Education at www.med.uc.edu/residency.

CAREER PATHS OF RECENT GRADUATES

Year of Completion	Program Graduate	Practice Type	Practice Location
1999	Jaime Aranda-Michel, MD	Academic	Mayo Jacksonville
2000	Raj Shah, MD	Academic	University of Colorado
2001	James Pilla, MD	Private practice
2001	John Sweeney, MD	Academic	Wake Forest
2002	Brian Isler, MD	Private practice
2003	David Florez, MD	Private practice
2003	Weizhing Wang, MD	Academic	NJ College Medicine & Dentistry
2003	Mark Scheidler, MD	Private practice
2004	Shailendra Chauhan, MD	Academic	University of Florida
2004	Michael Morelli, MD	Private practice
2004	Karlina Patton, MD	Private practice
2005	Sheeten Doshi, MD	Private practice
2006	Andrew Holt, MD	Private practice
2006	Greta Szabo, MD	Private practice
2007	Uri Avissar, MD	Academic	Boston University
2007	Sooyun Chun, MD	Private practice
2007	Christopher Duncan, MD	Private practice
2007	Kamran Safdar, MD	Academic	University of Minnesota
2008	Newton Muthunayagam, MD	Academic	University of Cincinnati
2009	Matt Atkinson, MD	Academic
2009	Terrance O'Toole, DO	Private practice
2009	Richard Song, MD	Private practice

Of the recent graduates of our training program over the last five years, 30 percent are presently in academic positions and 70% are in private practice.

CONTACT INFORMATION AND HOW TO APPLY FOR G.I. FELLOWSHIP

Please contact Ericka for general queries or information on the status of applications: Phone (513) 558-5588 or E-mail Ericka.Langhout@uc.edu

For specific program information, email Stephen Zucker, MD, Director of the GI training program at Stephen.Zucker@uc.edu.

Our program will be accepting applications through ERAS for the 2011 incoming year. Go to the ERAS website : http://www.AAMC.org/students/eras for details.

Applicants will be requested to provide the following information:

1) Three letters of reference
2) An updated curriculum vitae
3) Board scores (USMLE 1, 2, and 3) and Clinical Knowledge (including clinical skills)
4) Copy of medical school transcript
5) Documentation of visa or permanent resident status (if not a U.S. citizen)
6) Personal statement
7) Photo (optional)

Until all of these items are received, your file will not be considered complete.

NOTE:We do not accept email attachments.

Applicants must have successfully passed USMLE steps 1, 2 (both clinical knowledge and clinical skills exams), and 3 in order to be accepted into the program.

Mailing address:
Stephen D. Zucker, MD
Director, Gastroenterology Training Program
University of Cincinnati
Division of Digestive Diseases
231 Albert B. Sabin Way, ML 0595
Cincinnati, OH 45267-0595

Note: We have filled all of our training positions through the 2010 incoming year. We will be accepting applications through ERAS for one fellowship position commencing July 2011. Candidate interviews are planned beginning in January 2010. Our program will be participating in the 2011 National Residency Matching Program (NRMP) in gastroenterology.