Postgraduate Diploma in Clinical Hepatology

Purpose

The purpose of this qualification is to allow practising medical practitioners to develop skills in Clinical Hepatology to ensure safe practice in remote areas. This will enable improved management of acute and chronic liver disease as well as provide an informed triage and referral of selected cases to tertiary Hepatology services elsewhere. The Postgraduate Diploma is aimed at non-specialist Medical Practitioners to improve their overall skills and general management of patients with acute and chronic liver disease in low and middle income countries. The qualification is designed as a clinical apprenticeship, with the majority of the studying based on a close trainer to trainee ratio. Upon qualifying the learner will:

• Be able to improve the overall management of liver disease which is a cause of significant morbidity and mortality.
• Have a critical understanding of the theory relevant to the physiology, pathology, diagnosis and management of acute and chronic liver diseases.

Rationale

The burden of liver disease (particularly viral hepatitis, HIV and liver disease, alcoholic liver disease, non-alcoholic fatty liver disease and hepatocellular carcinoma) is significant in Africa and the complexity of available treatment modalities has increased significantly over the past two decades.

Hepatocellular carcinoma (HCC) is the third leading cause of death world-wide and 46,000 new cases of hepatocellular carcinoma are diagnosed in sub-Saharan Africa each year. 80% of these cases are due to Hepatitis B which is endemic in Africa. Hepatitis B is an entirely preventable disease and new treatment options can prevent the development of cirrhosis and hepatocellular carcinoma. An estimated 32 million people in Africa have Hepatitis C, another important cause of cirrhosis and HCC. Liver disease in patients with HIV/AIDS poses a particular challenge in the African setting. Apart from viral co-infection' opportunistic infections such as TB drug-induced liver injuries and other complications associated with the up-scaling and availability of antiretroviral therapy are seen in clinical practice. Recognising, diagnosing and managing these problems is critical in patients benefiting from antiretroviral therapy and preventingunnecessary morbidity. Many liver diseases are now eminently treatable, provided there is early diagnosis. Increasingly, patients from Africa with end-stage liver disease are referred abroad for liver transplantation and then return to their home countries where their medical caregivers have no training or experience in the long-term management of liver transplant patients.

Thus the aim of this Postgraduate Diploma is to train qualified non-specialist medical practitioners to enable them to practice Clinical Hepatology in order to diagnose, provide appropriate management and referral of patients with acute and chronic liver diseases in resource limited areas without the immediate supervision of a Specialist Hepatologist or Gastroenterologist with an interest in Hepatology. The intention of the qualification is not to create a sub-specialist Hepatologist. Rather, training in this instance is aimed at medical practitioners who are not specialists, but need to improve their skills in managing patients with liver disease. This is aimed at addressing an unmet and urgent need in South Africa and Africa for the appropriate clinical management of liver disease.

Recognition of Prior Learning (RPL)

The institution's official Policy for the Assessment and Recognition of Prior Learning (RPL) will be rigorously followed. Applicants who do not meet the admission criteria as stipulated, but who can demonstrate experiential or work-based learning at an appropriate level may be considered for RPL provided a proper assessment of the prior learning has been conducted. The process will be implemented in strict adherence to the relevant institution RPL Policy.

RPL may be used to grant credits towards the qualification.

Entry Requirements

For admission to this qualification, a learner must be

• Qualified with a Bachelor in medicine (MBBS, MBChB/equivalent qualification).
• Registered with the HPCSA.

The qualification comprises 2 compulsory modules at NQF Level 8 totalling 120 Credits.

Modules at NQF Level 8, 120 Credits

• Clinical management in Hepatology, 100 Credits.
• Long essay: Theory, Transition and Translation of Knowledge, 20 Credits.

1. Improve the overall management of liver disease which is a cause of significant morbidity and mortality.
2. Demonstrate a critical understanding of the theory relevant to the physiology, pathology, diagnosis and management of acute and chronic liver diseases.

Associated Assessment Criteria for Exit Level Outcome 1

• A history from the patient is obtained, a physical examination is performed, a differential diagnosis is formulated and an appropriate diagnostic and management plan are developed and implemented.
• A comprehensive and systematic knowledge base is displayed of the epidemiology of the principal diseases in Hepatology with emphasis in developing countries and the specific circumstances pertaining to Africa.
• Appropriate indications for and contra-indications to liver transplantation are understood.
• Emergency management of acute liver failure is performed.
• Complications of cirrhosis are managed.
• The diagnosis, investigation and treatment of a broad range of hepatobiliary disorders is displayed.
• The patterns of histological change and pathology are used and understood in the diagnosis of certain specific groups of liver conditions are understood.
• The prognostic criteria for acute liver failure and chronic liver disease are understood.
• The long-term follow-up of liver transplant patients; monitoring of immune-suppressant treatment and management of metabolic and infectious complications is understood.
• Diagnostic and therapeutic paracenteses are perfomed.
• The indications and limitations of a number of diagnostic and therapeutic procedures that are needed to manage hepatobiliary disorders are interrogated.
• Appropriate referrals are done and communicated with colleagues at referral centres.
• Ethical and rational decisions are made in difficult clinical cases in the setting of resource limited facilities.
• The need for a multi-disciplinary approach is understood (dieticians, surgeons, psychologists, radiologists, pathologists, and laboratory scientists).
• Effective communication and counselling skills with patients is displayed.
• Communication with Specialist Hepatology colleagues regarding management and referral of suitable cases for diagnosis, investigation and further management is displayed.
• Communication with the patients and their families regarding diagnosis and management of their liver disease is properly executed.

Associated Assessment Criteria for Exit Level Outcome 2

• Specialised investigations and procedures in Clinical Hepatology is understood and interpreted.
• Integrated knowledge of Clinical Hepatology is demonstrated and translation to own practice is shown.
• Different theories of Clinical Hepatology are evaluated.
• Techniques relevant to practise Clinical Hepatology is understood.
• An understanding of ethical and professional practices is understood in the context of managing acute and chronic liver diseases within the resource restraints of their country.
• Information from literature on Clinical Hepatology is gathered, independently validated and evaluated.
• The patterns of histological change and pathology used in the diagnosis of certain specific groups of liver conditions viz. viral/autoimmune/drug or toxin induced hepatitis, alcohol and non-alcoholic liver disease; collapse and sub-massive necrosis; biliary disease including sclerosing cholangitis, primary biliary cirrhosis, vanishing bile duct syndrome and biliary obstruction; inherited metabolic liver diseases and rejection of the transplanted liver - acute cellular rejection, chronic ductopaenic rejection and vascular rejection is understood and explained.
• The prognostic criteria for acute liver failure and chronic liver disease is evaluated.
• The long-term follow-up of liver transplant patients: monitoring of immunosuppression and management of metabolic and infectious complications is discussed.

Integrated Assessment

Integrated Assessment will be applied to assess the learners' competencies. This will be as follows

Initially formal assessment will be administered on completion of the first 3 months of the qualification. This form of assessment will be case-based oral assessments.

On-going feedback will also be provided at daily ward-rounds.

Thereafter a final Clinical Multiple Choice Question paper will be used as a type of summative assessment and a clinical case-based assessment will also be administered at the end of the training. Furthermore, learners will be expected to submit a Transition and Translation of Knowledge Essay.

In addition, A logbook must be completed documenting clinical cases seen; and procedures witnessed and performed; and topics presented. The range of clinical experience and procedures through documentation in the log book will be monitored and assessed.

Clinical MCQ paper, Clinical Case-based Oral.