Gaps in MASLD/MASH Education: A Quantitative and Qualitative Survey with Leaders of US Graduate Medical Education Programs

Introduction

Metabolic dysfunction–associated steatotic liver disease (MASLD) and its inflammatory subtype, metabolic dysfunction–associated steatohepatitis (MASH), are hepatic manifestations of metabolic syndrome.^1–3 In 2023, the nomenclature was updated from nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) to MASLD and MASH, respectively. In addition to the nomenclature change, the disease definitions were also updated, and the diagnosis criteria included the presence of at least 1 of 5 cardiometabolic risk factors.¹ MASLD and MASH are associated with cardiometabolic risk factors, including obesity and type 2 diabetes (T2D).^3,4 The prevalence of MASLD/MASH in the United States (US), and globally, is rising rapidly.^5,6 Furthermore, patients with MASH are at an increased risk of cirrhosis, hepatocellular carcinoma, requirement for liver transplant, and mortality.^7,8 Finally, MASH is also the leading cause of liver transplant in women and the elderly.^9,10 Therefore, education surrounding the rising prevalence of MASH and MASLD associated risk factors is important for emerging healthcare providers.

Despite its increasing prevalence, MASH remains largely underdiagnosed.¹¹ Proprietary data evaluating trial-ready participants with MASLD reported that <2% of patients with MASH are assigned an International Classification of Diseases, 10th Revision, (ICD-10) code for MASH in the US.¹² In another study, although the prevalence of fatty liver disease was 29%, only 1.6% of fatty liver disease cases had ICD codes recorded.¹³ According to a recent survey on practice patterns for MASLD, two-thirds of physicians reported that in more than half of the referred patients, the diagnosis of MASLD was either missed or delayed.¹⁴ Furthermore, over 50% of adults with risk factors for MASH go unscreened.¹⁵ Underdiagnosis is likely due to multiple factors, including the silent nature of early stage MASH for most patients, the perceived need for liver biopsy for diagnosis, and the paucity of approved pharmacotherapies for MASH in the US.¹⁶

Advances in biomarkers and noninvasive tests have improved the feasibility of screening for MASH and advanced liver fibrosis. Recent guidance recommends screening for advanced fibrosis in patients with T2D, medically complicated obesity, and MASLD in the context of moderate alcohol use and among first-degree relatives of patients with cirrhosis due to MASLD/MASH.¹⁷ However, a needs assessment study revealed that US physicians had significant gaps in knowledge regarding screening, diagnosing, and treating patients at high risk for MASH.² A recent review highlighting the patient and physician perspectives for MASH/MASLD also reported a need for patient- and provider-centered education to improve disease awareness, diagnosis, and management.¹⁸

We hypothesized that there might be an educational gap for healthcare professionals treating MASH, which may contribute to insufficient screening, diagnosis, and management of patients with MASH. To achieve our aim, we conducted an online quantitative survey and qualitative discussions with several program leaders in US graduate medical education training to quantify and expand their perspectives on how MASH-specific training is currently offered. This study also aimed to identify gaps between key competencies and current curricula and to uncover barriers and opportunities in current practices for the early identification and treatment of MASH.

Finally, we sought opinions on the recent nomenclature change from NAFLD/NASH to MASLD/MASH, a change that was introduced shortly after the quantitative survey was completed.

Materials and Methods

Study Design and Ethical Approval

This cross-sectional study included a quantitative survey and qualitative discussions with program leaders in primary care (internal medicine and family medicine) and specialty programs (hepatology, gastroenterology, and endocrinology) in the US. The quantitative survey was conducted from February 21 to May 24, 2023. Following the quantitative survey, we conducted two qualitative discussions among program leaders, one on August 24, 2023 and one on August 28, 2023. The study protocol was reviewed by the WCG Institutional Review Board and judged to qualify for exempt status due to the minimal risk posed to participants. The study was conducted in accordance with the principles of the Declaration of Helsinki; participant names were not captured by the study or associated with any analytic process. All study participants consented to the research. Their anonymity was preserved, and participants’ informed consent included the publication of anonymized responses and direct quotes.

Survey Design

Potential participants were recruited by postal mail with a link to access the online survey and were compensated upon completion of the survey. Follow-up reminders were sent by mail, email, and/or telephone. The survey instrument was developed by a market research firm (KJT Group, Inc., Rochester, NY, USA) with input from the program leaders, Appendix 1.

The survey lasted approximately 15 minutes and included yes/no, single-select, multiple-choice, and Likert-scale questions. Topics covered by the survey questions included respondent characteristics, respondent role within the program, program structure and curriculum focus, inclusion of NASH in the curriculum, perceptions of the appropriateness and importance of NAFLD/NASH in the curriculum, preparedness for NASH management, awareness of NASH management guidelines, expectations for curriculum evolution, barriers to curriculum modification, and opportunities for additional NASH education.

We conducted the quantitative survey before and the qualitative discussion after the official nomenclature change from NAFLD/NASH to MASLD/MASH. However, we used the terms NAFLD/NASH for most of the qualitative discussions. The MASLD/MASH nomenclature was introduced near the end of each qualitative group session, where we asked each group for their perspectives on the new terms. To ensure full transparency, we report participant responses using the actual terms used (NAFLD/NASH in most cases, MASLD/MASH where appropriate). However, we discuss our findings using the updated nomenclature of MASLD/MASH.

Participants

A list of US fellowship, residency, and training programs was developed from an online search of programs and used for recruitment. We identified 2599 potential programs and 3,550 potential contacts at these programs. Respondents were categorized as residency directors, medical program directors, deans, or assistant directors; US-based; and knowledgeable about curriculum development at their institution or program. Programs included hepatology, gastroenterology, endocrinology, internal medicine, family medicine residency or fellowship programs, US medical schools, nurse practitioner programs, and physician assistant programs. Only one program leader could participate from each identified institution or program.

Qualitative Discussion

After completing the online survey, program leaders were asked about their interest in participating in a qualitative discussion. Participating program leaders joined the discussion via a video conference call. They were asked to briefly introduce themselves without mentioning personally identifiable information, such as their full names or the institutions with which they were affiliated. Following introductions, question prompts and interactive polls were used to stimulate discussions among participants. The question prompts and interactive poll questions focused on roles and responsibilities, importance of education and training, time spent on education and training, current and potential coverage in curriculum, and reactions to the new MASLD/MASH nomenclature.

Statistical Analysis

Descriptive statistical analysis of deidentified quantitative data was conducted with Q Research Software (Displayr, Inc., Delaware, US), and Excel (Microsoft 365, Redmond, WA, USA). Data are presented as mean ± standard deviation (SD) or raw numbers and percentages rounded to the nearest whole number. Statistical comparisons were conducted with Q Research Software, and the level of statistical significance (P = 0.05) was calculated using z-test. The qualitative data analysis included summarizing common themes and aggregate sentiments. The complete discussion transcripts are included in Appendices 2 and 3. Although qualitative polls have a numerical value, due to the small sample size of participants, the qualitative data are grouped according to the following terms: “most” refers to 75% or more of the audience, “many” refers to more than half of the audience, “several” refers to about half of the audience, “some” refers to less than half of the audience, “few” refers to about 25% or less of the audience, and a “couple” refers to no more than two members of the audience. We also use direct quotations from the discussion transcripts to report our results. Participants were assigned participant numbers, and all personal identifying information was redacted from the discussion transcripts.

Results

Sample Characteristics

Of 2,599 potential programs identified, 239 individuals responded, of which 190 respondents completed the online survey; 49 did not meet inclusion criteria or refused to consent to the research. Nearly half of the quantitative survey participants (n = 94) were primary care physicians (PCPs). Approximately one-fourth of each program were specialty physicians or advanced practitioners (ie, nurse practitioner or physician assistant; Table 1). Of 190 respondents, 11 participated in the qualitative discussions representing the following specialties: primary care (internal medicine, family medicine, and nurse practitioner) and specialists (endocrinology, gastroenterology, and hepatology; Table 2).

Table 1 Characteristics of Graduate Medical Education Program Leader Respondents (N = 190) and Their Institutions. Self-Reported Results Collected by Online Survey in 2023

Table 2 Characteristics of Graduate Medical Education Program Leader Participants (N = 11) and Their Institutions

NAFLD/NASH Screening and Diagnosis

According to 38% of respondents, screening and diagnosis of NASH was covered “to a great extent” in their curricula (Figure 1). The most frequently covered diagnostic methods were ultrasound (88%), liver function tests (87%), liver biopsies (80%), aspartate transaminase to alanine transaminase ratios (78%), and lipid levels (73%; Figure 2). Only 34% of respondents reported covering the Fibrosis-4 (FIB-4) index test for primary risk assessment of patients at risk for MASLD (Figure 2). In the discussion group, most participants believed that MASH is largely unrecognized, leading to diagnosis at a point in which minimal options exist to alter its progression. In the primary care discussions, most respondents agreed that PCPs should play a role in identifying patients at risk for NAFLD/NASH; several primary care providers also indicated that gastroenterologists and hepatologists should be involved in risk identification (Table 3). However, only a couple of respondents said that endocrinologists should play a role. Participants in our specialist group also believed that primary care should play the major role in identifying patients at risk of NAFLD/NASH, screening patients for NAFLD/NASH, and diagnosing patients with NAFLD/NASH. The primary care group believed that hepatologists had a bigger role to play when it came to diagnosis and staging of NASH, but that they were less available in some communities. The specialist group agreed that specialists could be useful for disease staging, depending on the level of detail required for treatment.

Table 3 Representative Quotes From Graduate Medical Education Program Leaders Regarding NASH Screening and Diagnosis. Quotes From Two Group Qualitative Discussions, One Including PCP Program Leaders (n = 5), and One Including Specialist Program Leaders (n = 6)

Figure 1 Coverage of NASH core competencies in graduate medical education curricula. Abbreviation: NASH, nonalcoholic steatohepatitis. Note: Percentage of respondents (N = 190) reporting that they cover a topic to a “great extent”, “some extent”, “very little” or “not at all”. Results collected by online survey in 2023.

Figure 2 NASH diagnostics included in graduate medical education curricula. Abbreviations: AST:ALT, aspartate transaminase: alanine transaminase ratio; APRI, aminotransferase-to-platelet ratio index; CAP™, controlled attenuation parameter; CT, computed tomography; ELF™, Enhanced Liver Fibrosis Test; FIB-4, Fibrosis-4 index; MRE, magnetic resonance elastography; MRI/cT1, magnetic resonance imaging/corrected T1 mapping; MRI-PDFF, magnetic resonance imaging-proton density fat fraction; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; VCTE, vibration controlled transient elastography. Note: Percentage of respondents reporting coverage of specific NASH diagnostic tools in their curricula, among respondents who reported covering NASH diagnostic tools in their curricula (n = 187). Results collected by online survey in 2023.

Management of NAFLD/NASH and Associated Comorbidities

In the survey, 96% and 81% of respondents reported lifestyle modifications focusing on diet and exercise as part of NASH management, respectively. In qualitative discussions, the primary care group cited mixed feelings about their role in NASH treatment, largely because there was not a clear treatment for NASH at the time of the discussion. The primary care group saw a role for primary care in the management of NASH comorbidities and risk factors but believed staging falls into the hands of gastroenterology or hepatology (Table 4). Primary care providers saw a diminished role for gastroenterologists and hepatologists in the management of comorbidities. While acknowledging specialists’ limited time and resources, primary care providers thought an interdisciplinary approach would be ideal. The specialist participants agreed that, considering the current treatment landscape, primary care would play a major role in determining treatment in addition to hepatologists and endocrinologists.

Table 4 Representative Quotes From Graduate Medical Education Program Leaders Regarding NAFLD/NASH Management. Quotes From Two Group Qualitative Discussions, One Including PCP Program Leaders (n = 5) and One Including Specialist Program Leaders (n = 6)

NASH Education and Training

In the quantitative survey, only 22% (N = 190) of respondents reported that patient education for NASH was covered “to a great extent” in their curricula (Figure 1). This aligns with the qualitative discussions where primary care providers believed that all specialties had a role to play in patient education about NASH. Among specialists, ≥50% agreed that all specialties should contribute to patient education about NASH. In the quantitative survey, 96% (n = 183) and 92% (n = 174) of respondents reported that NAFLD and NASH were included in their program’s curricula, respectively. When asked on how important it is to include NASH education in their curricula, most respondents (83%) reported that it was very or fairly important to include NASH in their curricula. Similarly, primary care providers and specialists in the qualitative discussions believed that NASH education was important, and one specialist stressed the importance of early identification of NASH (Table 5). However, even with adequate NASH training, clinical implementation was deemed difficult. Primary care providers mentioned that NASH lacked the urgency of heart disease and cancer and noted the lack of a specific treatment for NASH.

Table 5 Representative Quotes From Graduate Medical Education Program Leaders Regarding NASH Education and Training. Quotes From Two Group Qualitative Discussions, One Including PCP Program Leaders (n = 5) and One Including Specialist Program Leaders (n = 6)

The quantitative survey respondents (N = 190) identified lack of room (time) in the curriculum (n = 100, 53%), lack of access to trained specialists or faculty expertise (n = 61, 32%), lack of treatment available for NASH (n = 58, 31%), lack of faculty interest (n = 51, 27%), and inadequate access to research on NASH (n = 38, 20%) as the top five barriers to integrating NASH education into their curriculum (Figure 3). In the quantitative survey, specialist respondents reported significantly more frequently than primary care providers (54% vs 27%, P < 0.05) that the lack of treatment available for NASH was a barrier to incorporating NASH in their curriculum (Figure 3). During the qualitative discussion, primary care providers agreed that an approved treatment for NASH could make NASH education more meaningful. Currently, more time is devoted to conditions such as cancer, where early detection is coupled with early treatment. Specialists highlighted the lack of dedicated NASH treatments and the difficulty in diagnosing NASH as reasons for the relatively low focus on NASH in their curricula. Primary care providers expressed mixed feelings about dedicating more time to NASH in the curriculum moving forward; those skeptical of spending more time on NASH cited lack of time, competing interests, and lack of specific treatment, whereas those in favor of spending more time on NASH cited the relative importance and prevalence of NASH. Primary care providers also cited the difficulty of enacting lifestyle changes and the lack of financial incentives as reasons more time is not spent on NASH education. Our specialist participants believed that they were already spending enough time, under the current circumstances, on NAFLD/NASH, but believed that primary care programs may need to invest more time into it. This feedback is in line with the quantitative survey results where primary care providers (n = 88) spent, on average, 7.5 hours (SD = 14.0) and specialists (n = 36) spent 22.8 hours (SD = 65.7) on NASH education.

Figure 3 Barriers to integrating NASH education in curricula. Abbreviations: NASH, nonalcoholic steatohepatitis; NP/PA, nurse practitioner/physician assistant; PCP, primary care physician. Notes: Percentage of respondents (N = 190) selecting reason as a “large” or “moderate” barrier. Results collected by online survey in 2023. aPercentage significantly differed (P ≤ 0.05) from percentage of PCP program respondents. bPercentage significantly differed (P ≤ 0.05) from percentage of specialist program respondents. cPercentage significantly differed (P ≤ 0.05) from percentage of NP/PA program respondents. *Indicates extremely small sample size (n<10).

Primary care participants also highlighted how the lack of expert speakers and the lack of certain technologies in their local care environments can hinder inclusion of NAFLD/NASH in curricula; similar findings were seen in the quantitative survey (Figure 3). Specialist participants predicted that more time would be devoted to NASH with the introduction of novel pharmaceuticals for NASH but stressed that there is a finite amount of time to cover many important diseases.

Primary care participants said that, although they generally follow and teach clinical guidelines to trainees, there can be discrepancies between what is advised in guidelines and what is reimbursed by payers, thereby limiting the utility of teaching certain guideline recommendations. Moreover, the NASH clinical guidelines most well known among respondents were from the American Association for the Study of Liver Diseases (AASLD); 48% (n = 92) of respondents were aware of AASLD guidelines for the diagnosis and management of NASH and, of these, 70 respondents (76%) said that AASLD guidelines were included in their curricula. One in five (n = 38, 20%) respondents were not aware of any clinical guidelines for NASH.

According to the survey respondents, major topics covered “to a great extent” in the NASH curricula included patient risk factor and comorbidities associated with NASH (46%), long-term complications and risk associated with the progression of NASH (43%), symptoms and clinical characteristics of NASH (41%), screening and diagnosis of NASH (38%), and lifestyle management of patients with NASH (37%). The topics that were “not at all” covered included clinical trials associated with NASH (28%), current off-label pharmacologic interventions for patients with NASH (23%), and genetic factors associated with NASH (18%; Figure 1). In the qualitative discussions, the primary care participants had mixed feelings about whether certain NASH core competencies were adequately covered in their curricula (Table 5). Participants believed that they covered most key core competencies, but the level of coverage might not be adequate. Despite inadequate coverage of certain competencies, some participants were skeptical that spending more time on them would translate to better outcomes for patients. One primary care provider also mentioned that NAFLD/NASH falls under the umbrella of their obesity topic lectures.

Primary care providers were not confident that their students were adequately prepared to manage NASH but did not specifically fault their curricula or their students. Instead, one primary care provider highlighted how, systemically, the US struggles to help patients with behavior-related conditions such as diabetes and obesity. The specialist group believed that their trainees were, in recent years, better prepared to manage patients with NASH, considering the increased exposure to patients with NASH in the clinical setting. However, the specialists were not universally optimistic about their trainees’ preparedness to manage NASH. A similar trend was seen in the quantitative survey, where only 12% of students in the primary care program versus 39% in the specialist program reported preparedness to manage patients with NASH. The specialists predicted that future trainees would struggle to keep abreast of new liver drugs coming to market, and that there would continue to be difficulties with coordinating multidisciplinary care and deciding which provider types would be responsible for each disease state.

Nomenclature Changes From NAFLD/NASH to MASLD/MASH

Both participant groups were asked about their level of awareness and perceptions of the NAFLD/NASH to MASLD/MASH nomenclature change that was released two months earlier. The primary care group had mixed feelings about the nomenclature updates (Table 6). They acknowledged the stigma attached to NAFLD, but some were particularly skeptical that the nomenclature update would provide value. One primary care provider described burdensome changes to their NAFLD clinic’s signage and website to accommodate the updated nomenclature. Both primary care and specialist participants believed that implementing the changes would take years, from at least 1 year to implement new ICD and electronic medical record codes, specifically, to the many years it could take the wider medical community to adopt the terminology. The specialist group had more positive reactions to the nomenclature updates while sharing many of the same concerns as the primary care group. The specialists predicted that there would be procedural complexities associated with the changes.

Table 6 Representative Quotes From Graduate Medical Education Program Leaders Regarding NAFLD/NASH Nomenclature Updates. Quotes From Two Group Qualitative Discussions, One Including PCP Program Leaders (n = 5) and One Including Specialist Program Leaders (n = 6)

Supplemental Learning Opportunities

In the quantitative survey, most respondents agreed that continuing medical education (CME, 72%) and online resources (72%) would be the most effective opportunities for additional NASH education outside of standard curricula. The discussion groups identified similar supplemental learning opportunities. One participant spoke highly of an online lecture series delivered by a NAFLD expert from the University of Louisville. One participant said that students today are less interested in reading journals and more interested in podcasts and online simulation case studies. Another participant said that they assigned their students monthly American Family Physician CME quizzes and noted that NAFLD was covered in a 2020 quiz. One participant said that the American Geriatric Society puts together high-quality, disease-specific slide decks and hoped that the AASLD would consider something similar.

A specialist respondent said that their trainees had access to general sessions and lectures offered by the Endocrine Society, the American Association of Clinical Endocrinologists, and the American Diabetes Association. The American Board of Obesity Medicine has a CME course that one trainee participated in, but otherwise, interest in the course was limited among specialist trainees. A variety of gastrointestinal and liver CME courses and conferences were brought up; one participant noted that these “... supplemental opportunities tend to get updated much more rapidly than [their] own curriculums.”

Discussion

In this quantitative survey, we found that most curricula covered MASH to some extent, and most program leaders perceived MASH education as important. Furthermore, the qualitative discussions with primary care and program leaders in specialist medical education highlighted the key role that primary care trainees play in combating the MASLD/MASH epidemic and the challenges that they face. Both groups believed that primary care would play the biggest role in both diagnosing and treating patients with MASLD/MASH. Program leaders in primary care and specialist also agreed that improving MASH education among primary care providers was critical. However, despite this recognition, most curricula lacked coverage of important MASH diagnostic or monitoring tools. FibroScan^® (vibration-controlled transient elastography) was covered by half of the programs, while the FIB-4 index test (a non-invasive blood test that uses a simple calculation of various parameters) and magnetic resonance elastography (a highly specific imaging technique) were covered by only one-third. These tests are among the most important components of disease recognition and all are recommended in the latest practice guidance from the AASLD and the American Association for Clinical Endocrinology on the clinical assessment and management of MASLD.^17,19 Less than half of program leaders reported including AASLD guidelines in their curricula, suggesting that trainees may not be receiving up-to-date guidance on screening and management of MASH. These findings highlight opportunities to improve MASH education among graduate medical trainees.

Our study identified lack of room (time) as the greatest barrier to expanding MASH education. The average time devoted to MASH education was approximately 9 hours. PCPs were skeptical that more time could be devoted to MASH in their curricula. By comparison, a survey of family medicine residency training professionals found that programs dedicated an average of 25 hours per year to “communication education.”²⁰ A survey of pharmacy school leaders found that an average of 3 out of 155 total credit hours was dedicated to obesity education.²¹ Medical knowledge continues to advance rapidly, and devoting more curriculum time to specific diseases is unlikely to be an effective strategy.²² If expanding time and resources dedicated to MASH education is not an option, then programs should consider where MASH resides in the larger framework of diseases covered in graduate medical education.

Another most frequently cited barrier to expanding MASH education was the lack of an approved treatment for MASH. The impact of the recent approval of resmetirom on MASH education remains to be seen. However, the approval of pharmacologic therapies for MASH is outside the control of medical program leaders, and introducing a MASH-specific therapy may encourage them to further integrate MASH education into their curricula. Program leaders believed that improved education around early detection of MASH had limited utility with the current reliance on behavioral lifestyle changes to treat MASH. Lifestyle changes (including changes to diet and physical activity levels) can be effective in treating chronic diseases such as MASLD/MASH and T2D.^23,24 A high-quality diet, increased physical activity, and college education are associated with a reduced risk of MASLD in the US.²⁵

However, lifestyle changes have proven difficult to successfully implement and maintain,²³ and participants in our qualitative discussions suggested that promotion of lifestyle changes lacks the financial incentive associated with medical procedures and pharmaceuticals in the US healthcare system. Instead, participants in this study suggested that curricular time would continue to be devoted to diseases with treatments that offered a clearer value proposition. Fortunately, there are signs that advancements in the MASLD treatment paradigm are arriving soon, with promising advances in drugs targeting reductions in hepatic steatosis, inflammation, and fibrosis, as well as bariatric surgical techniques.²⁶ In the meantime, leaders of medical training programs can aim to improve MASLD/MASH awareness by sharing supplemental learning materials provided by national medical societies. Almost three-quarters of respondents agreed that CME and online resources would be the most effective opportunities for additional MASH education outside of standard curricula. The AASLD recommends targeted screening of populations at risk for advanced liver disease, including people with T2D, medically complicated obesity, and/or those with significant alcohol use, to identify and manage patients with clinically significant liver fibrosis.¹⁷ Primary risk assessment, using the FIB-4 index, should be performed on patients suspected to have MASLD. Patients in low-risk categories can be managed in primary care while patients with multiple metabolic risk factors should be assessed with FIB-4 every 1–2 years.¹⁷ Patients with a FIB-4 score ≥1.3 should undergo secondary risk assessment (in primary care or specialist care), using additional tools such as vibration-controlled elastography, Enhanced Liver Fibrosis test, and/or magnetic resonance elastography.¹⁷

More than 70 international medical societies have endorsed the recent nomenclature update from NAFLD/NASH to MASLD/MASH, initiated by a Delphi consensus statement published in June 2023.¹ The reasons for the nomenclature update were twofold: firstly, the “nonalcoholic” language was based on negative diagnostic criteria that did not fully capture the etiology of MASLD, and, secondly, the “fatty liver” language was considered overly stigmatizing.¹ The participants in our qualitative discussion were aware of the nomenclature updates and accurately noted the reasons for the update. However, because we briefly introduced the nomenclature updates for discussion purposes, we could not use participant awareness as a proxy for unaided awareness of the updates. The recent nomenclature updates elicited mixed reactions from the primary care and specialist participants in our study, with specialist participant reactions being slightly more positive. Both groups were worried about transition challenges, including patient confusion, adoption of new diagnostic codes, and slow adoption by the wider medical community. More time is needed to properly evaluate the impacts of the updated MASLD/MASH nomenclature.

Limitations

Although the quantitative survey included a large sample size (N = 190), the overall response rate was low (9%). There could be differences between the curricula of programs whose leaders responded to our survey and those who did not. Moreover, this survey relied on self-reported responses from participants, which may reflect personal biases and perceptions that may not have wide generalizability. Also, the survey was undertaken prior to the FDA approval of resmetirom; therefore, responses reflect the previous state where there was no FDA-approved medication for the treatment of MASH. Furthermore, the qualitative study included a small sample size (N = 11) of US medical education program leaders, which limits our ability to generalize the findings to leaders of all US medical education programs. However, this limitation is bolstered by quantitative survey, which included a larger sample size (N = 190) and produced key findings that mirror the findings of qualitative discussions.

Conclusion

In conclusion, the increasing importance of MASLD/MASH education is recognized by the leaders of medical training programs, but curricular time devoted to MASH-specific education is limited by focus on other diseases with clearer treatment options. In the short term, medical training programs should seek to improve MASH-specific education, particularly for primary care providers, through supplemental learning opportunities such as online resources, workshops, CME, and collaboration with national medical societies. In the future, the approval of MASH-specific therapies could represent an impetus to devote more time and resources to MASH-specific education.