Clinical Program Description

Inpatient Experience

The liver fellows spend approximately 6 months of the year on the inpatient liver transplant service at Columbia University Medical Center. They are responsible for evaluating and providing care to liver patients in the hospital under direct attending supervision. With 25-30 patients on service at any given time and approximately 130 liver transplantations performed a year, the in-patient service is a multi-disciplinary service staffed by an attending hepatologist and liver transplant surgeon, 2 surgical interns, 4 medical interns, 2 physicians assistants (PA's) and medical and surgical fellows. The liver service is responsible for all patients prior to and following transplantation, complex liver cases admitted by one of the attendings or seen in consultation, and patients with hepatobiliary diseases or malignancies undergoing surgery. The service assumes primary care for patients in the ICU and on the general medical floors. The fellows have supervisory and leadership roles on the service and are directly responsible for the care of both pre- and post-transplant patients. All urgent liver biopsies performed are reviewed daily by the team with Dr. Lefkowitch in the Pathology Department. Endoscopy and ultrasound guided liver biopsies on all patients on the service are shared by the transplant hepatology fellows.

Outpatient Experience

The liver fellows spend two half-days a week in the outpatient clinics while on inpatient rotations (at the Columbia campus), or six half-days a week while on outpatient months (at the Cornell campus). This clinic time includes a continuity clinic, which totals two half days of clinic weekly at the Columbia campus with Dr. Brown. This allows ongoing mentored development of clinical skills with assessment by a senior faculty mentor. All the clinics include pre- and post-transplant patients at both the Columbia and Cornell campuses. The practice is a consultative practice limited to liver diseases and sees a broad array of diagnoses including a large population of patients with hepatitis B and C, alcoholic hepatitis, autoimmune hepatitis, benign and malignant neoplasms of the liver, and difficult tertiary care problems in hepatology. All clinics within the CLDT are multidisciplinary and are staffed by attending hepatologists (Drs. Brown, Dove, Verna, Fox, Gaglio, Wattacheril, Jesudian, Fortune and Lucero) and hepatobiliary/transplant surgeons (Drs. Emond, Kato, Guarrera, Greisemer, Halazun and Samstein). In addition to the attending staff, NP's and PA's as well as rotating medical residents, students, and GI fellows participate in evaluating patients. Each session includes extensive teaching, radiologic review, and case discussion. Office hours have a particular focus on each day and are staffed by at least one attending hepatologist, one surgeon and their collaborating NP's and PA's.

The transplant clinic sees 10-12 new transplant evaluations per week as well as following the >300 patients on the transplant waiting list and all post-transplant patients. The fellows are exposed to the management of end-stage liver disease and its complications, the workup of patients for living and deceased donor liver transplantation, and the evaluation of the potential living donor. On the post-transplant patients, immunosuppressive management and prevention and treatment of long-term complications including recurrent hepatitis C and other diseases, osteoporosis and renal dysfunction will be stressed. Recognition of early complications including both surgical problems (wound infection, hernia, biliary complications) and medical complications (CMV, rejection) are integral skills acquired in the post-transplant clinic. Longitudinally, a nurse practitioner cares for transplant patients in the CLDT in conjunction with a collaborating attending transplant hepatologist. Additionally a large pediatric hepatology practice is followed two days a week if the adult liver transplant fellow desires exposure to pediatric liver disease.

Procedures and Other Clinical Experience

Liver biopsies are performed 4 mornings a week by the attending hepatologist and the fellows will be able to perform >50 supervised liver biopsies on native and allograft livers with pathologic interpretation during the year. Biopsies are performed using both ultrasound and percussion guidance. All ultrasounds for liver biopsy are performed by the fellow and confirmed by the attending hepatologist. The service currently performs approximately 500 liver biopsies per year in the inpatient and outpatient setting. The fellows also performs both inpatient and outpatient endoscopy, and have exposure to advanced procedures including ERCP for biliary complications after transplant will also be available. They participate as an observer in at least 3 liver procurements, at least one of which will be for living liver donor procurement, and at least 3 recipient transplant operations, at least 1 being a living donor recipient as required for UNOS certification as a liver transplant physician.

Conferences and Colloquia

During the transplant fellowship, all fellows are members of the Division of Digestive and Liver Diseases at Columbia and attend and contribute to all teaching conferences of the Division (see table below). Four additional conferences within the Center for Liver Disease & Transplantation (CLDT) are multidisciplinary involving hepatologists, surgeons, oncologists, radiologists, and psychiatrists. At these conferences, the fellows are expected to present patients he has evaluated in both the outpatient and inpatient settings, discuss relevant findings and participate in the formulation of a clinical plan. In addition, the Center for the Study of Hepatitis C at Cornell/Rockefeller and the Comprehensive Transplant Institute at New York-Presbyterian has frequent lectures on immunobiology, pathogenesis and advances in hepatitis C science and therapy. Fellows are also encouraged to attend the annual meetings of the American Association for the Study of Liver Diseases (AASLD) and the American Society of Transplantation (AST).

Facilities

The Center for Liver Disease and Transplantation

Formed by the merger of the two university hospitals of Columbia and Cornell, New York-Presbyterian Hospital is a leader in medical care and research. The Center for Liver Disease and Transplantation (CLDT) was created at the time of the merger, and as part of a Comprehensive Transplant Institute at New York-Presbyterian, CDLT is a multidisciplinary center with a fully integrated team of experts in medicine, surgery, radiology and pathology. The Center has grown to perform ~130 liver transplants a year. It includes one of the largest adult-to-adult liver transplant programs in the country and an active pediatric liver transplant program. The CDLT has clinical offices and faculty at both Columbia and Cornell, and combined there are 9 transplant hepatologists in the program, as well as 8 hepatobiliary surgeons, 2 psychiatrists, 4 surgical and 3 transplant hepatology fellows, 7 nurse practitioners, 3 social workers, 10 research coordinators, and an administrative support team.

Columbia University Division of Digestive and Liver Diseases and Center for Translational Immunobiology

The Division of Digestive and Liver Diseases at Columbia University College of Physicians and Surgeons comprises 23 full time faculty members as well as 11 voluntary physicians. There are 12 clinical fellows in the ACGME gastroenterology fellowship program and three clinical fellows in the ACGME transplant hepatology fellowship program as well as advanced endoscopy, nutrition, and several research fellows in the laboratory.

Weill-Cornell Medical College and the Center for the Study of Hepatitis C

In addition to the clinical program within the GI Division at Columbia, the cross-University program in liver transplantation affords the applicant access to the resources in liver disease at the Cornell campus of New York-Presbyterian. The fellows spend several months in the outpatient clinics at Cornell. This provides a dedicated outpatient experience in pre-and post-transplant care. Dr. Brown conducts two-half day clinics per week and Drs. Jesudian, Fortune and Lucero have 4 sessions each. In addition, the applicant will participate in the Center for the Study of Hepatitis C, a research center founded as a joint endeavor of New York-Presbyterian and Rockefeller University. Co-directed by Dr. Charles Rice, it provides a research core center whose mission is to promote research on aspects of the physiology and epidemiology of hepatitis C. The center has an active enrichment program offering a regular series of research seminars, symposia and visiting professors that are designed to enhance the research atmosphere in liver diseases at Columbia and Cornell.