Master of Philosophy in Advanced Hepatology and Transplantation

Purpose

The primary purpose of this qualification is to train subspecialists in advanced hepatology and transplantation. Such subspecialists - hepatologists - will be able to focus on the various types and aspects of liver disease and become integral members of liver transplant teams.

Successful graduates will be able to

• Run dedicated liver units and liver transplant programmes in South Africa.
• Research independently critical issues relating to liver disease and liver transplantation that are relevant both internationally and in the South African context.
• Teach at both undergraduate and postgraduate level.
• Understand and assist in clinical study design and protocol development.
• Contribute to regional and national health policy.
• Apply bioethics in the management of both patients and in research.

Rationale

Both the burden of liver disease (particularly viral hepatitis, HIV and liver disease, non-alcoholic fatty liver disease and malignancy) and the complexity of available treatment modalities have increased significantly over the past two decades. There is also increasing liver transplant activity in South Africa and thus a clear need now exists for subspecialty physicians specifically trained in advanced hepatology and transplantation.

The current gastroenterology training does not allow for the included training in advanced hepatology and transplant hepatology because of the many demands in medical gastroenterology created by of the advances and expanding skills required for gastroenterologists in the area of luminal gastroenterology, as well as in the management strategies and options now available for inflammatory bowel disease. There is thus inadequate time available to optimally train in the skills and expertise necessary in current hepatology and transplant hepatology practice.

This deficiency has been recognised internationally, resulting in the offering of specialised programmes to develop the required expertise in advanced hepatology and transplantation. In addition, with the growing recognition and registration of various subspecialties, few trainees are prepared to undertake training in a discipline where there is no formal certification. A more fundamental and real practical concern is that, with the change in the remuneration system for doctors in the public sector to the Occupation Specific Dispensation (OSD) system, only designated posts may be utilised to train specialists. Thus, without a formal training programme and posts available, the ability of Departments to allow for ad hoc training in non-formally recognised disciplines such as hepatology is no longer possible. Without the ability to train, the discipline will unfortunately stagnate and existing expertise will disappear with the passing of time.

Learners undertaking studies for this qualification must

• Comply with the requirements for Registration as a Medical Practitioner as prescribed by the Medical, Dental and Supplementary Health Services Act.
• Be registered as a specialist one of the primary specialities listed against the relevant subspecialty in terms of the Act.
• Be appointed against a HPCSA-approved training number.

Recognition of Prior Learning

Admission to this Master's Degree could be granted to learners not in possession of the specified Degree that meets the admission requirements at the discretion of the Institution and in accordance with the relevant legislation.

Access to the Qualification

Prior to commencing with education and training in the relevant sub-speciality, learners must be able to provide proof of:

• Compliance with all the requirements for registration as a specialist in one of the primary specialities listed against the relevant sub-speciality.
• Registration as a specialist in that field.
• Appointment as a learner by the HPCSA.

This qualification comprises two compulsory parts, viz., Hepatology and Transplantation theory and prescribed practical procedures - 120 credits and a relevant dissertation not exceeding 20 000 words - 60 credits.

All the credits are at NQF Level 9. Total required credits for the qualification: 180.

Master of Philosophy Advanced Hepatology and Transplantation, Part 1: 120 Credits

Modules

• Anatomy, histology, molecular biology, embryology and development of the gastrointestinal tract and liver.
• Physiology and pathophysiology of the gastrointestinal system (digestion, absorption, secretion, motility, metabolism and immunology).
• Diagnosis, pharmacology, adverse reaction, efficacy and appropriate use of drugs in the management and treatment of various types of gastroenterological disease, inter alia, peptic ulcer disease, inflammatory bowel disease, iron deficiency, anaemia pancreatic disease.
• Epidemiology of common digestive disorders.
• Indications, contraindications and complications of endoscopic procedures and the uses, cleansing and care of endoscopic instruments and ancillary devices.
• Macroscopic and microscopic anatomy of the liver, its vascular supply and the biliary drainage system of the liver.

Master Philosophy Advanced Hepatology and Transplantation Part 2: 60 Credits

Dissertation

Identify a research project in Advanced Hepatology or Transplantation and complete the following stages

• Prepare a research proposal.
• Complete a literature review.
• Collect and collate data.
• Analyse finding/s.
• Draw conclusions.
• Make recommendations.
• Prepare the dissertation of no more than 20 000 words in length.

1. Demonstrate the ability to assess and evaluate critically ill patients.
2. Demonstrate management skills in directing the institution of appropriate medical care, including all modalities of advanced organ support.
3. Demonstrate the ability to direct and advise on diagnostic and exploratory investigations of patient acuity with an emphasis on providing directed patient care.
4. Identify, plan and manage issues pertaining to health care at institutional, organisational and community levels.
5. Formulate and manage appropriate intervention strategies directed at the provision of advanced organ support.
6. Participate effectively and show the lead in decision- and policy-making activities and provide reliable advice.
7. Appreciate the responsibility and power in exercising professional judgment or expertise in the field of hepatology.

Critical Cross-Field Outcomes

Graduates will be able to

• Identify and solve problems in the hepatology and liver transplant environment.
• Work effectively with others as a member of a team, group, organisation or community.
• Assess and evaluate patients with a view to the provision of appropriate specialist care; express opinions on likely outcomes and the validity of the liver transplant process.
• Collect, analyse, organise and critically evaluate information with regard to patient acuity.
• Communicate effectively using visual, mathematic and or language skills in the modes of oral and/or written persuasion.
• Use science and technology effectively and critically, showing responsibility towards the environment, individual patients and the health of others.
• Show an understanding as to the rationing of resources in an environment that may not be able to offer critical care to all patients.
• Commit to life-long learning.

The following Assessment Criteria are applied in an integrated manner to encompass all the Exit Level Outcomes.

• Awareness of the bioethics involved in the clinical management of patients as well as in research protocols is clearly demonstrated.
• Ethics and a professional approach are clearly demonstrated at all times, whether dealing directly with patients and/or their significant others or in the pursuit of research and the production of an original dissertation.
• Acquisition of competence in the performance of specific diagnostic and therapeutic procedures, and understanding of their associated indications, contraindications, complications and interpretation is clearly demonstrated.

Range of diagnostic and therapeutic procedures

> Percutaneous liver biopsies (Perform at least 10).

> Diagnostic and therapeutic paracenteses (Perform at least 20).

> Oesophagogastro-duodenoscopies (Perform at least 250).

> Upper gastrointestinal haemorrhage endoscopies (Perform at least 30 of which at least 10 must be therapeutic).

> Interpretation of oesophageal manometries (Perform at least 10).

> Observation of Endoscopic Retrograde Cholangiopancreatographies (ERCP) (Observe at least 10).

> Comprehensive evaluation of patients for liver transplantation (Perform at least 10).

> Peri-operative liver transplant management of patients (Manage at least 10 patients).

> Ongoing follow up of liver transplant patients (Follow up at least 10 patients).

- Managerial, teaching and academic skills are clearly demonstrated in the

> Conducting of a clinical audit.

> Managing of admission policies.

> Developing of core teaching material to enable participation in teaching programmes.

> Organising a postgraduate teaching programme.

> Providing formal and informal teaching at undergraduate and postgraduate level.

> Critical evaluation of clinical results from audits, papers and literature reviews.

• Comprehensive knowledge of the macroscopic and microscopic anatomy of the liver, its vascular supply, the biliary drainage system of the liver, all aspects of the physiology and pathophysiology of the liver is demonstrated in the following:

> Performing comprehensive and accurate patient assessments.

> Demonstrating understanding of the roles and limitations of the various diagnostic and therapeutic procedures in the assessment and treatment of biliary disease.

> Being technically competent in the performance of these procedures.

> Recognising, preventing and managing complications of chronic liver disease and cirrhosis.

> Demonstrating an in-depth knowledge of the indications for and both the relative and absolute contraindications of liver transplantation within the South African context.

> Demonstrating knowledge of the timing, required preparation and management of pre and post liver transplantation patients.

• Humanitarian and caring skills are demonstrated in the support given to terminal patients and their families and/or significant others to maintain dignity through the provision of palliative and continued care.
• Research skills are clearly demonstrated in the following:

> Application of the principles of clinical study design and protocol development.

> Application of the data collection process (including collation, database development).

> Data analysis and interpretation including medical statistics and data presentation.

> The publication of at least one article in a peer-reviewed journal.

Integrated Assessment

Formative Assessment

Theoretical and Clinical Learning

• Clinical competence of learners is assessed daily on clinical ward rounds.
• Academic knowledge is also assessed weekly at the liver academic meetings.
• Formal three-monthly meetings are held to discuss progress and areas of concern.

Dissertation

• Weekly meetings with the supervisors to ensure progress with the research project.

Summative Assessment

Learners write the College of Medicine examination for the Certificate in Gastroenterology: Advanced Hepatology and Transplantation, which examination comprises:

• One three-hour written examination incorporating both clinical and basic science elements.
• At least two (three if deemed necessary) clinical cases.
• A one-hour oral examination which may include applied anatomy, physiology, pathology and radiology.