Young GI angle: Challenges in education of liver transplantation gastroenterologists

Liver transplantation has now become the standard of care for individuals with end-stage liver disease or acute liver failure.1 This advancement has led to a rising need for hepatologists skilled in transplant medicine, leading to the development of transplant hepatology education. Trainees are required to master the clinical management of advanced liver diseases and address ethical and psychosocial care aspects while also caring for transplant recipients and managing disease recurrence and/or post-transplant complications.1 Consequently, becoming a transplant hepatologist requires dedication to training, teamwork, and frequent ethical decision-making. My educational journey began in Zagreb, Croatia, where I graduated in 2018. Due to the lack of formal transplant fellowships in Croatia, I pursued the UEMS Transplant Curriculum and passed the examination in 2023, completing my formal education. Since 2019, I have been working in the medical ICU of the University hospital Zagreb, focusing on critically ill patients with cirrhosis and liver transplant-recipients. By sharing my experiences, I hope to provide guidance to fellow trainees and offer a basis for comparing educational experiences with peers. My career path in hepatology, particularly liver transplantation, was significantly shaped by two key factors: early exposure to a specific patient population, and connecting with a mentor involved in transplant hepatology. These experiences not only made the initial years of my residency more manageable but also influenced my decision to specialize in transplant hepatology. During my residency at the University Hospital 'Merkur', a major liver transplant centre, I was extensively exposed to critically ill patients with cirrhosis. This provided me with an understanding of the complexity of advanced liver diseases. Simultaneously, my involvement in the outpatient clinic allowed me to witness the transformative impact of liver transplantation, which solidified my inclination toward transplantation. Furthermore, the role of mentorship in shaping my career trajectory became evident early on. Meeting the right mentor, a very ambitious and dedicated transplant hepatologist, was key. My mentor was not only responsible for overseeing my work in the outpatient clinic and inpatient service, but also influenced my decision to pursue and presevere through my doctorate, and introduced me to the broader hepatology and transplant community. Being a Zagreb native, I was lucky to complete my training without relocating. However, trainees from other Croatian regions must undergo parts of their specialized training within a university hospital, with liver transplantation education solely available in Zagreb, thus underlying the potential inequity within the same country. Any robust training system is supported by standardized certifications which evaluate a candidate's ability to deliver evidence-based care and navigate the ethical dilemmas in liver transplantation.1, 2 It is worth noting that, contrary to the EU, transplant hepatology in the US requires formal training through a 'transplant hepatology fellowship' to be completed after a GI fellowship. As mentioned earlier, I completed the UEMS transplant curriculum. The preparation was time-consuming, as by this time, other work and family responsibilities make it difficult to dedicate time for studying. On a positive note, ample educational activities are offered, such as specialized courses and online materials. The Hesperis course provides an invaluable opportunity to meet peers and discuss exam strategies, and I was fortunate to attend the first post-pandemic live session. For aspiring transplant hepatologists, I advise starting early and methodically. Attend the Hesperis course, connect with professionals who have taken the exam, and use the abundant on-line resources. Furthermore, the UEG Clinical Fellowship offers a valuable opportunity for trainees to enhance their knowledge, skills and professional connections, with placements available at centres specializing in transplant hepatology. Last, but not least, check if there is a certification programme and exam available within your home country, similar to Italy's programme endorsed by the Italian Association for the Study of the Liver (AISF).2 In the late stages of residency and early post-fellowship period, the importance of teamwork and learning to handle criticism became clear themes. Despite overall improvements in patient safety, many adverse events still stem from miscommunication. Skills such as resolving conflict and being open to feedback are essential for improving team performance and ensuring patient safety. Developing a positive attitude towards constructive criticism is crucial for both professional and personal growth, requiring humility and a willingness to learn from.3, 4 As I approached the later stages of residency, the importance of resilience against burnout became increasingly clear. The demanding nature of patient care, long hours and frequent on-call shifts can push patients to exhaustion. Burnout, characterized by emotional exhaustion, depersonalization, and reduced accomplishment, is prevalent among transplant hepatologists. Having a well-equipped team with more than five colleagues, feeling at ease with the clinical workload, confidence in previous training, sufficient time for outpatient visits, high resilience and positive emotions, and the ability to consult senior physicians all reduce the risk of developing significant emotional exhaustion.5 Furthermore, recognizing symptoms, fostering resilience through support from peers and family, setting boundaries, and benefiting from effective mentorship and structured support programs are crucial for maintaining both professional and personal well-being.6 While I have no personal experience with AI, I have been interested in reading about its prospects in transplant hepatology. AI techniques could potentially improve diagnostic accuracy and treatment efficacy in transplant medicine. The-LEOPARD-project, now underway, seeks to enhance liver transplantation outcomes by creating an AI-based predictive algorithm which could ensure more timely transplants and equitable access, thus reducing the waitlist mortality.7 The field of transplant hepatology faces a paradox: the demand for specialists grows, yet there is a shortfall in new talent entering fellowship programs.8 A study investigating gastroenterology fellows' career choices in hepatology highlighted the impact of training duration and board certification pathways on their decisions. Optimizing certification to 3 years instead of four could tip the scales towards hepatology. The study also identified deterrents such as lessened endoscopy time and inadequate financial reward, while incentives included personal fulfilment, case complexity, and forming lasting patient relationships.8 Reflecting on my journey in transplantation hepatology thus far, I am grateful for choosing this path. To attract younger professionals, we need to optimize fellowship programs and strengthen mentorship. As advancements in the field of solid organ transplantation shape the future of education, it is crucial to define educational strategies and embrace new technologies. By doing so, we can prepare the next generation to face the challenges ahead with expertise, compassion, and resilience, ultimately improving patient care and professional fulfilment. Research data are not shared.