MEETING REPORT

Future Trends in Hepatology: Challenges andOpportunities

Vinod K. Rustgi,1 Gary L. Davis,2 Steven K. Herrine,3 Arthur J. McCullough,4 Scott L. Friedman,5 and Gregory J. Gores6

As a professional society, the American Associationfor the Study of Liver Diseases (AASLD) is animportant instrument for coordinating and focus-

ing the professional objectives of hepatology. As a preludeto an AASLD-sponsored strategic planning initiative, aFuture Trends Meeting was convened on January 4-5,2008. The focus was on the burden of liver disease, thecurrent status of AASLD U.S. physician members, exter-nal forces shaping the profession, and manpower/trainingparadigms. Despite enormous advances in the preven-tion, diagnosis, and therapy of patients with liver diseases,

the burden of liver disease in the United States is substan-tial. There is an unmet public health need for professionalexpertise in liver diseases, which is not addressed by cur-rent training paradigms. New models of care are needed,funding challenges for sustaining hepatologists need to beaddressed, and new training paradigms conceived and im-plemented. The information reviewed and emerging so-lutions developed to address the above challenges arereviewed herein. As a new AASLD strategic plan emergesto further refine the concepts developed at this meeting, itwill be published in a separate document.

Secular Trends in Liver DiseasesDespite advances in diagnosis, disease-specific inter-

ventions, and hospital care, liver-related mortality has re-mained relatively stable over the last 30 years while overallmortality in patients with liver disease has declined slight-ly.1 Much of the overall mortality is due to reduction indeaths due to gallstone disease and gallbladder cancer.1

Overall liver-related mortality rate exclusive of gallblad-der disease has remained relatively stable during this time,though chronic liver disease mortality declined from 1979to 2004 and has remained steady since that time.1 Thefactors involved in these trends are complex and vary bythe cause of liver disease.

Hepatitis A virus (HAV) is the most common cause ofclinically apparent acute viral hepatitis, accounting forabout half of cases.2 However, the estimated incidence ofacute HAV infection and its age-adjusted mortality havefallen dramatically during the last decade.1,2 HAV vaccineis highly efficacious, and its more widespread use wouldresult in further reductions of the infection. Althoughacute HAV infection can result in considerable short-term morbidity, particularly in adults, it does not result inchronic liver disease and therefore its contribution tohealthcare resource utilization has declined significantly.

Hepatitis B virus (HBV) is the most common cause ofacute hepatitis virus infection and is estimated to accountfor about a third of clinically apparent cases of acute hep-atitis.3 The incidence has declined over the last two de-cades, probably as a result of widespread vaccine use inhigh-risk groups and reduction in high-risk behaviors. Avariable proportion of acute cases develop chronic infec-tion, and it is estimated that about 1.25 million persons in

Abbreviations: AASLD, American Association for the Study of Liver Diseases;ABIM, American Board of Internal Medicine; ACGME, American College ofGraduate Medical Education; HAV, hepatitis A virus; HBV, hepatitis B virus;HCC, hepatocellular carcinoma; HCV, hepatitis C virus; NAFLD, nonalcoholicfatty liver disease; NIH, National Institutes of Health; PQRI, Physician QualityReporting Initiative.

From 1Transplant Surgery, Georgetown University, Fairfax, VA; 2Division ofHepatology, Baylor University Medical Center, Houston, TX; 3Thomas JeffersonUniversity, Philadelphia, PA; 4Department of Gastroenterology and Hepatology,Cleveland Clinic Foundation, Cleveland, OH; 5Division of Liver Diseases, Mt.Sinai School of Medicine, New York, NY; and 6Division Mayo Clinic, Rochester,MN.

Submitted on behalf of the American Association for the Study of Liver Diseases(AASLD) Governing Board by Gregory J. Gores, M.D., Mayo Clinic, College ofMedicine, Center for Basic Research in Digestive Diseases, 200 First Street SW,Rochester, MN 55905.

This work was supported by the AASLD, 1001 North Fairfax Street, Suite 400,Alexandria, VA 22314.

Participants in the Future Trends Conference included: P. Angulo (MayoClinic), B.R. Bacon (St. Louis University), G.L. Davis (Baylor University), L.D.DeLeve (University of Southern California), R.M. Dickler (Association of Ameri-can Medical Colleges), J.E. Everhart (National Institute of Diabetes and Digestiveand Kidney Diseases), G. Fitz (University of Texas Southwestern), S.L. Friedman(Mt. Sinai Medical Center), G. Garcia-Tsao (Yale University), G.J. Gores (MayoClinic), D. Hanto (Beth Israel Deaconess Medical Center), S.K. Herrine (ThomasJefferson University), J.H. Hoofnagle (National Institutes of Health), W.R. Kim(Mayo Clinic), L. Langdon (American Board of Internal Medicine), N.F. LaRusso(Mayo Clinic), D. LaBreque (University of Iowa), T.J. Liang (National Institutesof Health), M. Lucey (University of Wisconsin), J.J. Maher (University of Califor-nia San Francisco), A. McCullough (Cleveland Clinic), J.G. McHutchinson (DukeUniversity), V.K. Rustgi (Georgetown Universtity), A.J. Sanyal (Virginia Com-monwealth University), C.I. Smith (University of Minnesota), J.M. Vierling (Bay-lor University)

Address reprint requests to: Vinod Rustgi, Georgetown University, Fairfax, VA.E-mail: hepgi@aol.com; fax: 703-698-9256.

Copyright © 2008 by the American Association for the Study of Liver Diseases.Published online in Wiley InterScience (www.interscience.wiley.com).DOI 10.1002/hep.22451Potential conflict of interest: Dr. Davis received grants from Human Genome

Sciences, Roche, Schering-Plough, and Vertex. Dr. Rustgi received grants fromHuman Genome and Hoffmann-LaRoche. Dr. Herrine received grants from Roche,Shering-Plough, and Human Genome.

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the United States have chronic hepatitis B.2 This numbermay be rising as a result of immigration from areas wherethe infection is endemic. Indeed, the prevalence ofchronic HBV infection may be as high as 9%-21% amongAsian immigrants.4,5 Nonetheless, age-adjusted mortalityand the number of patients requiring liver transplant foradvanced hepatitis B are declining, which are likely attrib-utable to the availability and effectiveness of antiviraldrugs.6 On the other hand, data from the National Am-bulatory Medical Care Survey (NAMCS), National Hos-pital Ambulatory Medical Care Survey (NHAMCS), andthe National Hospital Discharge Survey (NHDS)7 all in-dicate that HBV-related disease is accounting for an in-creasing number of clinic and hospital visits, most likelydue to the high prevalence of chronic infection and newtreatment options.

The discovery of the hepatitis C virus (HCV) in 1989,which enabled screening of blood products, resulted in amarked fall in the incidence of new infection beginning in1990.1-3 However, a large proportion of acutely infectedindividuals develop chronic hepatitis, resulting in an esti-mated 2.7 million to 5 million infected persons in theUnited States.8,9 As a consequence of ever-improving an-tiviral therapies, the number of ambulatory care visits andinpatient admissions have more than doubled since1990.7 Disease modeling predicted a surge in HCV-re-lated morbidity and mortality over the first two to threedecades of this century, which is now being realized, al-though recent mortality data suggests that the trend maybe reaching a plateau.2,10,11 Furthermore, the number ofliver transplants for complications of chronic hepatitis Chas remained relatively stable since 2000.12

Hepatocellular carcinoma (HCC) accounts for662,000 deaths worldwide per year and is the third lead-ing cause of cancer-related death.12 In the United States,HCC currently accounts for only about 16,000 or 2.9%of cancer deaths.13 However, the age-adjusted incidencehas more than doubled in the last 20 years.14 The over-whelming majority of HCC occurs in patients withchronic viral hepatitis13,15 and the recent increase is drivenby the high prevalence of chronic HCV infection.10,11

The average annual risk of HCC is 3.2% in patients withcirrhosis from HCV.16,17 The annual risk is also high inpatients with chronic HBV infection, ranging from0.1%-1.0% among patients positive for hepatitis B sur-face antigen who did not have cirrhosis to 2.2%-3.2% inpatients with cirrhosis.17 Loss of detectable HBV or HCVwith antiviral therapy decreases the risk of subsequentHCC, but does not eliminate it.18,19 The SurveillanceEpidemiology and End Results database reports that76%-95% of patients with HCC die as a direct conse-

quence of tumor progression.14 In fact, HCC now ac-counts for 50%-70% of liver-related mortality.20,21

The prevalence of obesity has more than doubled in theUnited States over the last 30 years and is now at least35%.22 Nonalcoholic fatty liver disease (NAFLD) is com-monly associated with obesity and/or accompanying met-abolic syndrome. It has been estimated that 10% ofchildren and adolescents and 34% of adults have hepaticsteatosis.23,24 Steatosis or steatohepatitis are present in65% and 20% of obese individuals, and in 90% and 50%of the morbidly obese (body mass index � 40 kg/m2),respectively. Those with central obesity have a hazard ra-tio of 2.2 for death due to cirrhosis.25 Overall, patientswith NAFLD have reduced long-term survival, with liverdisease accounting for about 10% of overall mortality,surpassed only by malignancy and cardiovasculardeaths.26,27 Clearly, it appears that NAFLD will become amore prevalent problem in coming years.

The above analysis indicates that the burden of chronicviral liver diseases is substantial and translates into a sig-nificant public health problem. Therapies for these dis-eases have become increasingly complex and requirespecial expertise. The emergence of hepatobiliary neopla-sia and NAFLD as public health problems also will re-quire additional medical resources. Although predictionsregarding the future are difficult because they can be dra-matically altered by disruptive technologies (for example,percutaneous ablation) and therapies, the future demandfor hepatology expertise and manpower is likely to grow.The future U.S. physician manpower need is currently anarea of controversy.28,29

Current Demand for HepatologistsAlthough there were 3,362 dues-paying members in

the AASLD in 2007, only 1,630 (46%) of these wereU.S.-based physicians. Furthermore, only 52% of thisU.S. physician membership considered the AASLD theirprimary professional societal affiliation based on a mem-ber survey. Consistent with this information, only 55% ofmembers indicate that more than 50% of their clinicalpractice was solely focused on patients with liver disease.A majority of the membership have an academic appoint-ment and participate in a liver transplant program. Al-though the majority of AASLD members are in academicinstitutions, only a small minority conduct laboratory-based research (14%), whereas the majority view clinicalcare as a primary job description. Thus, although the ma-jority of hepatologists are academic and transplant physi-cians, a large number practice combined gastroenterologyand hepatology. Changes in training models (vide infra)must take this dual practice preference into account. Thelack of individuals with careers in discovery-based re-

656 RUSTGI ET AL. HEPATOLOGY, August 2008

search is of concern for the advancement of the profes-sion.

There is an unmet demand for transplant hepatolo-gists. For example, as of September 2007, there were 45advertised positions for hepatologists. The open positionswere widely distributed throughout the United States.These data suggest that almost one-half of all United Net-work for Organ Sharing (UNOS)-approved liver trans-plant programs (124 as of April 14, 2008) are recruitinghepatologists. If all 36 American College of GraduateMedical Education (ACGME) training programs intransplant hepatology are successful in recruiting andtraining transplant hepatologists, these positions could befilled over the next several years. However, not all of theACGME positions are currently filled, and retention ofhepatology faculty is challenged by issues of work-life bal-ance and remuneration. The demand for competent,well-trained hepatologists is likely to continue.

To date, hepatologists are gastroenterologists who de-sire marketplace salaries commensurate with their train-ing. Also, hepatologists are in demand, which furtherenhances their market value. The practice of hepatology ispredominantly cognitive, and examination and manage-ment charges are insufficient to cover salaries. Yet, thedownstream revenue from a hepatology practice is sub-stantive.30 A wide variety of models for support of hepa-tologists have been developed to address these complexissues (Table 1). These models intertwine support fromhospitals and transplant programs. All of these modelshave strengths and weaknesses in their implementation,and a universally accepted model does not exist.

Given the differentiation of hepatology from gastroen-terology and its integration within transplant programs, acompelling rationale can be developed for the creation ofindependent hepatology divisions within departments ofmedicine. The strengths of these divisions are their focuson “all things liver” and the optimal integration of basic,translational, and clinical hepatology. The weaknesses areoften their small size, which limits flexibility and financialsolvency. Currently, there is no national consensus on theadvisability of separate hepatology divisions.

Private Practice HepatologyFor those who practice hepatology outside of an academic

institution, the majority practice outpatient hepatology withan integrated group practice or gastroenterology practice.From an analysis of a large midwestern gastroenterologygroup practice, Minnesota Gastroenterology, 10%-15% ofall evaluation and management codes were hepatologycodes. Care of hepatology patients in this practice was laborintensive (more than six visits per year versus two visits peryear for gastroenterology patients). There is a significant fi-nancial disincentive to treat hepatology patients in the pri-vate practice setting because of the lower reimbursement(compared to endoscopy) and the necessity for chronic dis-ease management. Also, the private practice is not a benefi-ciary of the hospitalized care of these patients who are usuallyreferred to tertiary care centers for hospitalization. Modelsfor health care delivery will need to incorporate these issues toprovide adequate hepatology care for the U.S. population.Nonetheless, the opportunity for large, integrated gastroen-terology (GI) practices to help solve the problem of treatingliver patients is substantial. The combination of manage-ment tools, midlevel providers, creative contracts with third-party payers, and physicians with expertise and training inhepatology can help address these challenges.

Quality Measures in PracticeQuality measures and indices will affect the practice of

hepatology in the future. Quality has been defined by theInstitute of Medicine as the provision of care in a safe,effective, patient-centered, timely, efficient, and fair man-ner.

Although the federal Health Care Quality Improve-ment Act was passed in 1986, the clarion call to changewas instigated by the death of 39-year-old Boston Globemedical columnist Betsy Lehman from an accidentaloverdose of chemotherapy. The Institute of Medicinelaunched its quality initiative in 1996, publishing theseminal papers “To Err is Human,” and “Crossing theQuality Chasm” in 1999 and 2001, respectively. Withwide public awareness of the avoidable morbidity andmortality of medical errors, the U.S. Department ofHealth and Human Services redoubled its efforts to re-duce such events. As part of the Tax Relief and HealthCare Act of 2006, the Physician Quality Reporting Ini-tiative (PQRI) was established by the Centers for Medi-care and Medicaid Services. Intending to enhance thevalue of care provided to Medicare beneficiaries, thePQRI authorizes bonus payments for practitioners whovoluntarily report on quality measures.

The development of quality measures, which form thebackbone of PQRI, is a process which continues to be

Table 1. Models of Support for Hepatologists

● No direct support for hepatology● Direct hospital support● Indirect hospital support through a transplant program● Direct support from transplant surgical departments● Creation of a fiscally independent, multidisciplinary transplant institute or

center● Cross-subsidization of hepatology by proceduralists within divisions of

gastroenterology

HEPATOLOGY, Vol. 48, No. 2, 2008 RUSTGI ET AL. 657

shaped. Quality measures, as promulgated by PQRI,must be developed, as well as endorsed or adopted by avoluntary consensus standards body, defined as an entitythat maintains openness, balance of interest, due process,an appeals process, and consensus. Once developed, mea-sures must be endorsed by the National Quality Forum oradopted by the AQA Alliance (formerly the AmbulatoryCare Quality Alliance) prior to inclusion in PQRI.

As a member of the American Medical AssociationPhysician Consortium for Performance Improvement,the AASLD (in collaboration with the American Gastro-enterology Association [AGA] Institute) was involved inthe development of measures related to the managementof hepatitis C, which were adopted in the 2008 Medicarequality reporting program along with many other PQRImeasures. The AASLD is also committed to the develop-ment of Patient Improvement Modules, instrumentswhich are required in American Board of Internal Medi-cine (ABIM) Maintenance of Certification programs, andwhich may be helpful in the development of future qual-ity measures suitable for submission to PQRI.

As the Centers for Medicare and Medicaid Serviceschanges from a passive payer to active purchaser of ser-vices, incentives for higher resource utilization withoutregard to patient outcomes or quality of care will vanish.As a result, the development, endorsement, and imple-mentation of quality measures will continue to expand,becoming an integral part of health care delivery. Hepa-tologists and the AASLD must be proactive and partici-pate in this process. Currently, the lack of focus on qualitymeasures represents an unmet and critical professionalopportunity in hepatology.

Training in HepatologyCombined with an increasing prevalence of advanced

liver disease and HCC due to the epidemics of viral hep-atitis and obesity-related liver disease, advances in hepa-tology care have led to an unmet need for hepatologyexpertise that is likely to widen in the coming decade.Nonetheless, there are no reliable data defining what per-centage of patients with liver disease are currently man-aged by appropriately trained individuals (eithergastroenterologists or hepatologists). A compelling indi-cator of the unmet need are the dozens of unfilled facultypositions for transplant hepatologists in academic centersthroughout the United States (see “Current Demand forHepatologists” above). Still, more reliable data is urgentlyneeded to assess whether patients with liver disease haveadequate access to the most advanced, high-quality care.Nonetheless, it is clear that creative models are needed toaddress the unmet demand for specialized hepatologycare.

The formal development of an advanced hepatologytraining fellowship, a major significant step toward ad-dressing this unmet need, was conceived by the AASLDwith the cooperation of the related GI societies and ulti-mately approved by the Gastroenterology Board of theABIM. This initiative followed a workforce study commis-sioned by the AASLD in 1998-1999 that helped establishhepatology as a distinct subdiscipline of gastroenterology. Astandardized curriculum was established, certification statuswas granted by the ABIM, and training programs were ap-proved by the ACGME. The effort was consummated withthe first examination in Transplant Hepatology offered inNovember 2006. Two hundred sixty-one individuals sat forthe examination, with 87% achieving a passing score certi-fying expertise in this discipline.

Despite this momentous step toward increasing the train-ing of hepatologists, a number of constraints continue tolimit the emergence of an adequate workforce. Principalamong these is the length of this advanced training, whichrequires individuals who are interested in hepatology at thetime of their internal medicine residency to first complete a3-year fellowship in gastroenterology, during which theymust apply for separate hepatology training thereafter.Lengthened training of this type is viewed more broadly bythe ABIM as a deterrent to U.S. medical school graduateschoosing internal medicine and its subspecialities for theircareers. Combined with mounting debt of many medicalschool graduates, the increasing demand for clinical gastro-enterologists to meet the need for expanded colon cancerscreening, and the increased remuneration for these posi-tions, there is significant attrition in the number of traineesinitially attracted to a career in hepatology who ultimatelypursue this pathway. Moreover, acceptance into GI fellow-ship is intensely competitive at present, such that any candi-date interested in hepatology who fails to obtain a fellowshipslot in gastroenterology is effectively denied the chance tobecome a hepatologist through the conventional trainingroute.

With this background in mind, there is a growing im-petus for further refinement in hepatology training toshorten its duration and increase the availability of spe-cialists. If successful, such an effort is likely to improve thequality of care and accelerate further advances in the field.

Although a number of potential pathways are possible,including direct entry in a hepatology training programafter internal medicine residency, the most appealing op-tion is to utilize the existing framework of a 3-year GIfellowship to offer more accelerated entry into advancedhepatology training within this 3-year period (Table 2).Specifically, candidates interested in a career in hepatol-ogy could indicate this interest in applying to designatedfellowships that offer 1 year of general gastroenterology

658 RUSTGI ET AL. HEPATOLOGY, August 2008

followed by 2 years of advanced hepatology training. Ad-ditional fellowship slots are envisioned to meet this needrather than redirecting current GI fellowship slots towardthis purpose. The hepatology portion of the fellowshipwould eventually replace the current fourth-year ad-vanced hepatology fellowship and incorporate all its cur-ricular components. A specialized examination would berequired to certify this advanced level of hepatology ex-pertise, either as part of a customized GI fellowship exam-ination or as a separate, complementary test akin to thecurrent advanced hepatology examination.

This hepatology track within a GI fellowship wouldyield a number of tangible advantages. It would: (1)shorten the overall training period for hepatology by 1year; (2) allow hepatology trainees to begin their special-ized liver training 2 years earlier than in the current train-ing model; (3) obviate the need for a separate applicationto hepatology fellowship; (4) provide a grounding in gen-eral gastroenterology with proficiency in standard endo-scopic procedures (upper endoscopy and colonoscopy)that are part of a typical hepatology/gastroenterology hy-brid practice; and (5) offer a component for research,although additional training beyond this period wouldlikely be required for laboratory-based trainees or thoseseeking advanced degrees in patient-based research (forexample, Masters in Public Health or Masters in ClinicalResearch).

This proposal is also consistent with the ABIM’s goalof shortening training and accelerating the entry into themost specialized, last phase of clinical training. Moreover,this template for further subspecialty training within the3-year GI fellowship period could be expanded by the GIBoard of ABIM in partnership with related societies(AGA, American College of Gastroenterology, AmericanSociety for Gastrointestinal Endoscopy) to establish sim-ilar training programs in other subdisciplines, for exampleinflammatory bowel disease, motility, and advanced en-doscopy, among others. This proposal would have noimpact on trainees seeking training in general gastroen-terology under the current fellowship format, whichwould continue to offer 30% of the training period inhepatology.

Ongoing dialogue will be essential to further refine thisproposal and adequately align the interests of key stake-holders including other GI-related societies, the ABIM,the American Board of Medical Specialties, and theACGME, among others. Additional data are needed toquantify the current unmet need in specialized hepatol-ogy care. Nonetheless, there is rising impetus for changein the current hepatology training paradigm, and theAASLD is committed to providing responsive leadershipin seeking creative solutions to the benefit of patients withliver disease.

Funding for Academic HepatologyHepatology represents a burgeoning field in academic

medicine not only in the United States, but also through-out the world. There has been, and continues to be, ro-bust growth in research, education, and clinical care. Thisdegree of unprecedented historic growth and expansionhas served to highlight the intrinsic strengths of hepatol-ogy as a broad-based discipline, and simultaneously, hasfocused attention on mechanisms to fund academic hepa-tology in medical centers. This perspective will dissect theopportunities for funding and the vehicles for navigatingthem.

Recognizing that a plateau of the National Institutes ofHealth (NIH) budget ensued after an unparalleled dou-bling in the budget, it is nonetheless important to empha-size NIH grants as the prominent source of funding forscientists and clinicians engaged in basic, translational,population, and patient-oriented research in hepatology.Given the NIH Roadmap Initiatives and the NationalInstitute of Diabetes and Digestive and Kidney Diseases(NIDDK) Action Plan for Liver Disease Research (http://www2.niddk.nih.gov/AboutNIDDK/ResearchAndPlanning/Liver_Disease/Action_Plan_For_Liver_Disease_Intro.htm), itis equally important to emphasize interdisciplinary research inliver and biliary diseases. Apart from R01 and related ProgramProject (P01),Center (P30), andconsortium(U01) funding forinvestigators, it is critical to emphasize the identification andnurturing of fellows and junior faculty through NIH traininggrants, fellowships, and career development grants. Although itis natural to look to the NIH as the predominant source offederal funding, selective opportunities should be pursuedthrough other federal agencies, such as the Veteran’s Adminis-tration and Center for Diseases Control and Prevention.

It will be increasingly important to complement fed-eral funding sources through other vehicles. These relateto alliances with pharmaceutical and biotechnology com-panies and private philanthropy to support and fosterinvestigator-initiated as well as programmatic efforts. Thegastroenterology or hepatology division can play a greatrole in these endeavors given the wide prevalence and

Table 2. Current and Proposed Training Models inHepatology

Current (4 years) Proposed (3 years)

GI Training (3 years) GItraining(12months)13 months GI Hepatology training and research (24 months)5 months Hepatology6 months Research12 months Electives

Hepatology training (1 year)

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incidence of diseases such as viral hepatitis B and C, non-alcoholic steatohepatitis, fibrosis, cirrhosis, HCC, portalhypertension, and parallel considerations of liver trans-plantation.

The unique roles of transplant hepatology, as a subdis-cipline of hepatology, shape a number of complex inter-actions between hepatology, departments of medicineand surgery, transplantation centers, medical schools, andhospital/health system administration. Transplant hepa-tology fuels primary and downstream revenue gains, butthe transplant hepatologists require subsidy as a platformfor fiscal viability from a clinical perspective for eitherhepatology divisions or hepatology programs within gas-troenterology divisions. These complex interactionsshould be pursued in a manner that is mutually beneficialto all involved parties, and plans need to be durable overtime. Transient arrangements, namely those arrangedfrom year to year, tend to be distracting and prevent long-term planning of faculty recruitment and retention. Atthe same time, hepatologists should also work to increasethe fiscal viability of the specialty by broadening the reachof their practice through inclusion of hepatic oncology,imaging, and interventional procedures such as transjugu-lar pressure measurements and transjugular intrahepaticportosystemic shunts.

Academic hepatology is vibrant with a bright, energeticfuture. The explosion of new information from all sectorsof research and clinical care and the need to groom futurehepatologists through formalized education and trainingprograms conspire to make hepatology attractive as a spe-cialized discipline. Funding for academic hepatologyneeds to take into account traditional (federal, state, city)and nontraditional (industry, philanthropy) sources forresearch funding, as well as intrainstitutional collabora-tions and partnerships for clinical revenue allocation.These two cardinal features furnish a strong platform forhepatology. Long-term strategic planning is necessary toavoid transient solutions and intermittent fluctuations,because the latter result in disruptions in faculty develop-ment, recruitment, and retention, which in turn have ad-verse consequences on trainees. Academic hepatology ispoised to play a prominent role in academic medical cen-ters into the next decade.

Unfortunately, current and projected NIH funding,by all assessments, will remain static. Furthermore, federalregulation of industry support for academic research isconstrained and unlikely to change in the future, againbased on various evaluations. These troubling factors posea serious impediment to critical components of academicmedicine, in particular as they relate to the recruitmentand retention of junior faculty hepatologists, who are thevery essence of the future of hepatology. Thus, there is an

urgent and compelling imperative to diversify the sourcesof funding for research. To that end, fundraising throughphilanthropy needs to be a top priority. The creation andmaintenance of revenue from philanthropy would permitthe AASLD to endow research granting mechanisms forfellowships, junior faculty scholar awards, and bridgefunding.

Although it is a new area for AASLD, the thrust forfundraising would be enhanced by the following:

1. Creation of a fundraising foundation under the aus-pices of the AASLD

2. An annual budget for the fundraising foundation3. Goals for revenue generation4. Membership donationsOne can only surmise universal support for this ven-

ture so that AASLD can continue to carry out its missionas well as support its membership, particularly those whowill constitute its future.

SummaryThe tremendous progress in the science and practice of

hepatology in recent decades, fostered by the AASLD, is agreat success story. Effective vaccines, antiviral therapies,liver transplantation, and the bounty of emerging diag-nostics and therapies reflect important dividends frominvestment in basic and clinical research, and point to-ward a golden era in the specialty in the coming years. Yet,many challenges must be overcome to realize this poten-tial. These include: (1) epidemiologic trends that portenda rising incidence in several types of chronic and neoplas-tic diseases; (2) growing disparities between the need foradvanced hepatology care and the availability of ade-quately trained practitioners to provide it; (3) limited op-tions for supporting the salaries of hepatologists whosepractices do not include either transplant hepatologyand/or endoscopic procedures, reflecting a lack of suffi-cient recognition of the highly cognitive, demanding na-ture of clinical hepatology; (4) a growing focus ondefining and implementing quality measures; and (5)constrained extramural funding for basic, translational,and clinical research.

Key recommendations that have emerged from the2008 Future Trends Conference include the need for theAASLD to:

1. Modify current training paradigms to accelerate theentry of motivated trainees into the specialty of hepatol-ogy, in order to expand the workforce to meet these grow-ing needs.

2. Support evolving practice paradigms and regulatorychanges to more fully recognize the unique skill set anddemands of clinical hepatology, which should promoterevised metrics for reimbursement.

660 RUSTGI ET AL. HEPATOLOGY, August 2008

3. Maintain a leading voice, in partnership with re-lated societies and government agencies, in defining andimplementing quality measures that will improve out-comes for patients with liver disease.

4. Continue to seek new sources of research funding tocomplement the ongoing support from NIH and otherfederal agencies, in order to realize the research goals out-lined in the NIH Action Plan for Liver Disease. Theseefforts will include new initiatives for independent fund-raising by the AASLD from philanthropy and othersources, and partnership with sister organizations to cre-ate synergies that will accelerate basic, translational, andclinical research advances.

These recommendations will be complemented by aStrategic Planning Initiative in 2009 to clarify prioritiesand optimize approaches to achieve these goals. TheAASLD is committed to tackling these challenges andmaximizing the opportunities with creativity and deter-mination.

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