Thank you, Michele and Aparna. It's a pleasure to be here. So what I'm going to do is I am going to finally tell you about a day. I'm not going to go over hour to hour, but I'm going to zoom out, zoom in, and then zoom out, then zoom in. So I hope that my slides will tell you what I mean. I have no disclosures to share. And Oren alluded to that before I tell you what a day of a community hepatologist. I think it's important to know what a hepatologist is, because if you don't, then we don't know what a hepatologist would be like anywhere. And this is part of a paper that we basically co-authored. And what this tells you is that the definition is quite wide, which basically means that whatever fits your plan I think should fit okay, because if you look at that in your GI practice and you get to do more than 50% hepatology, and that's okay, then that would be okay for you. So that's basically the goodness of that definition, so to speak, is that it has some resilience. But the practice settings, when you talk about community, you talk about two things, basically, either private practice or hospital-based. And a private practice, you're less likely to see transplant patients, but it's possible. And the ideal example of that is Dr. Shiffman, who has basically been extremely successful in being a bonafide prime hepatologist in the community. He evaluates patients, refers them to MCV, extremely successful practice. But again, the prototype in general is that more likely than not, you're not going to be able to see those patients. You're more likely to see GI patients, have GI night calls and procedures. If that's something that you like to do, I think that would be something to consider. With hospital-based, there are these transplant centers or non-transplant centers, and transplant centers, there are about 20 nationwide. We're one of them in Advent Health. There's Atrium Health, North Carolina, Ochsner, Piedmont, Swedish. They're usually associated with some transplant centers that they refer to. For example, Wake Forest, I know, refers to Atrium Health. The setting includes variable involvement in GI. If you are in those hospitals, it depends on how many GIs they have. So small hospitals in general, if you're in the community, without transplant center, you're more likely to do quite a bit of GI. So that's something to expect. In transplant centers, your involvement with GI is going to be variable. And again, depending on the nature of the employed GI practices in the institution and the community specifics, because there are community GIs that would refer to you. So it's important to know before you go, making assumptions, I'm going to be doing ERCPs and all these things, to know the landscape that you're going to go to, as well as deliver and transplant volume, basically, that you're doing. But before I go too far, I have to tell you that in the Allied Physician Institute, they've been publishing data on the physician employment and hospital acquisitions. And hospital acquisitions of private practices has been on the rise, and it's been astronomical. So if you're considering a private practice, especially a small practice encircled by big institutions, I think it's fair to study that landscape and make the right assumption that more likely than not those practices may end up being acquired. I know lots of cases, not just in hepatology. I have a patient who's a urologist. He joined practice, went to a small hospital to get privileges. A year later, he was acquired by a bigger health system, and he had to change gears to a different institution. But nevertheless, it's been on the rise astronomically. So the impact of that for physicians, the shift toward employment, you lose autonomy. You're a private practice. You're the king of your own, in a sense. So you lose that if you're hospital-employed, if you like this independence. In contradistinction, it does offer alleviation of the burden of having an independent practice. And you have to consider that the payer mix, if you're independent, will tend to start favoring those large health systems because that's when they get their contract satisfied at a cheaper price. Employed physicians in hospitals tend to make more money out of outpatient procedures within hospitals than if you do it in your own practice. For example, a colonoscopy would be $1,800 in a hospital outpatient department, $1,300 in a private practice. So the higher HOPD services are higher cost to Medicare. Whether that changes over time, I think we have to wait and see. But, again, that's reality. So academic versus non-academic, if I have to reflect on that, I would say that university hospitals define the location. For example, I was in Baltimore. Hopkins defines Baltimore, not otherwise. So you don't go to Baltimore because it's an attraction. You go to Baltimore because Hopkins is there. AdventHealth attracts you not because it's a Hopkins of Orlando. It is a big institution in Orlando, but you go because Orlando is a good place to live. It's not a general rule across the board. Obviously Boston has it both. You have Harvard, and it's a great city to live in. But usually those tend to be lines that these institutions use. There's more directed marketing in community hospitals, such as where I am, for disciplines and institutions. It tends to be institution-driven by the hospital, by the dean, by the big business development office, not by yourself. There tends to be closer ties with community GIs in community hospitals, but it's a very fine line in case you complement their practice and not steal their practice. You shouldn't replace them in a community hospital because that's your referral line. In a university hospital, you don't have that problem. You're the mecca. Whether that patient stays with you, it doesn't affect the institution. So those stronger community relationships, they're earned in the community. They're assumed or inherited in a university setting. At Hopkins, you're a Hopkins doctor the minute you join. You stop being so the minute you leave. So you have the Hopkins name or the Harvard name by the minute you are there, and that's also a consideration. In the community, you have the opportunity to lecture, to connect with the community, so you earn your respect. Even in a big institution, the minute you deal with a lecture or anything, you have an authority already. You represent a mecca of knowledge. So this is my history. I did medicine, GI fellowship, fourth year is transplanted pathology, ended 2004. I was offered a contract. I signed it on the table. I didn't read it. I had no idea what my salary was. I saw what Dr. Brown said. I had no slush funds to start the lab. I did have 900 square feet of lab, but no money to buy pipettes. And I had 50-50 protected time. But I was lucky. I had phenomenal mentors, Anna May, Steve Mazzei, Jim Potter, to name a few. I pretty much immediately got a pilot grant from the NIH, and that was my start-up fund. Later I did get the SLD Scholar Award. I encourage you to get it, to apply. That guaranteed the real 50% protection for me. Until then, it was negotiable. I got some three R01 co-investigators, and then I got a patient who gave up money, 100,000 a year for five years, and then we were writing the first R01, and that's when I was approached by Orlando. And I have to tell you, if you ever think, as Dr. Brown said, money versus no money, good and bad, I think you're thinking the wrong path. You just have to start thinking to declutter your interests. And if there's one interest that if you're left without, would you be happy doing what you do? And if you answer that, then you've got the right job. So then I moved to Orlando after I declined, but I ended up moving. So AdventHealth Orlando, it's a huge hospital. It's a little shy of 1,300 beds. There are six hospitals, 3,500 acute beds, 75-plus transplants, plus or minus with peds liver. It's a multi-organ transplant program under one transplant institute, which is a blessing and a curse, and one administration, again the same. It has solid high-expertise service lines across the lines that I listed, Red Onc, IR, examples of good things that you can do potentially in institutions like that, even though it's hard to negotiate things, is that we got a Mars machine and a FibroScan with little negotiation, justification of business, justification of why we should get it. There are residencies, internal medicine, surgery, few fellowships, no GI. We're working on it. There are affiliations with UCF and Florida State. And there is clinical research. However, when you do these things, you do it out of interest, not because you're building a CV. You can be from Duke once. You can be from Harvard once. But those things that you end up doing, they're your real interests, and you start enjoying it. In the institute, I would say it's a leveled medical-surgical service line. There's one institute, Shared Resources, because when you have multiple transplant disciplines, it can be very difficult to align needs for one organ over the other. But nevertheless, I see it. It's a positive overall. There's a lot of collegiality, and this is something you should look at, because if you really don't like the people there, then you shouldn't be there. The good thing there, at least in my experience, is that hepatology schedule is MD-driven. We put the schedule. We have half an hour for follow-up patients, an hour for a new patient. There's a whole spectrum of fluid disease that you can see. I want to briefly talk about contract. We've all seen this paper and heard talked about, about downstream revenue. This is good to know. I put it first. Don't really bet on it too much. Administrators are going to listen to it if they don't like it. I like what Dr. Brown said, and I'm building on it. I would say look at the program stability, the transplant outcomes, your colleagues, the staffing. It's important. You're not going to be working in a vacuum. The other organ systems, how successful they are, the administration. And you can easily buy in whether they're buying into the program and its success. It's not hard to notice. And if promised and essential for your success to assume that job or career, then it should be written. If you don't see it written, then it's not going to happen. And I can tell you that contracts can change any time, so don't really get married to the minutiae details in the contract, because they can change that in 24 hours. So you either build this element of trust after all these things make sense to you, or you don't. As I said, there are certain essential things that you think are foundations for your success. Then if they're not written or if you don't feel it, then basically you should walk away. The RVU conversions, the bonus structures, the billing department, I think you should look at that. And, yes, look at the community. That is the referring base. So, again, academic hospital versus private. In academia, invariably, I didn't get it, but there was a slush fund. There used to be a – I mean, there is a slush fund, a startup. Part A is a uniform salary. Part B is your administration. And Part C is your bonus. The RVU models tend to change. They're different between different institutions. For example, at Hopkins, if you met it, you got some bonus. In community hospitals, there is sign-in bonus. These are negotiable. There is less guarantee in terms of your contracts. There is a trust versus written promises, NPE staff. And there is a slew of RVU conversions, quality, metric, salary-based versus plus or minus quality. If you go to private, you own it. But mostly I see people joining private practices as salaried physicians, non-partner trajectories. The work life, I do trust that there is work life. It can be achieved. It tends to be low in academia if you're overly busy and you don't control your schedule. And it tends to be higher in community hospitals, especially if you think you moved into the right place. It is variable in private, but it's a killer if you're a junior because you eat what you kill, and that's a burnout potential. And I think in private practice, the work life is proportional to seniority. So the more senior, the more work life balance you have. Education or clinical research is highest in academia. It goes lower as you go to private. The academic hierarchy is stiff in academia. There's a chair of medicine. They can barely know your name. There's a dean who's not on the slide because they really don't know who you are. You don't see a hospital here on the chart because you really don't interact with the CFO. The CFO pressures the internal medicine chair. The chair pressures your GI chief, and GI chief pressures your directors and yourself as faculty. This is not good and bad. This is what happens. There are silos of medicine and surgery, so you have to understand that landscape, why the surgeon has more resources than you do even though both of you deal with the same patient with transplant. Our system, there's a CEO for the whole system, like seven hospitals, 3,500 beds. Underneath, there's a CEO of the hospital, and there's a chief operating officer. I am the medical director and surgical director. We should be on paper reporting to the abdominal director, and all of us reporting to the senior administrator. It's really not the case in a very strict way. We do report to the COO who reports to the CEO, but we do interact with all of the above. The landscape is a little bit flatter, at least in this system, that they tend to know you and interact with you. This is quickly my academic-based transplant hepatology. There's more that is not on the table. There's a lot of clinics, lots of meetings. There's grant writing. There's research. There's education, internal medicine, leading their physiology course. There's inpatient, about two to three months. GI calls when I am on call. There's early meeting and grant rounds. And this, I thought I'll die doing this. I mean, I really enjoyed it. This is my schedule now. It appears to be cleaner. It's a little bit cleaner. The clinic, I control it better. I have more freedom controlling the schedule, but we do have pretty good outcomes. And I do have a slew of meetings that I wish they're not there, but you can't escape it, I think. But I still get to do the things I like to do. We teach. I go to the community. We have residents rotating with us. We do clinical research, and we do great work with people like Oren at the ASLD. So the takeaway in terms of compensation, yes, it goes up as you go to private, but I don't think it should be distressed. It is an important factor. If you have kids, you have to take care of them. When I moved, my daughter was 7. My son was 5. And I'm glad I moved. I'm proud of where I came from. I still have my adjunct position. But autonomy, I think it's highest in private, but it can be a killer if you're the young person not on tenure to be a partner. And beware that this species is evading because it's being bought by hospitals. Grants and stress promotion. I did not see myself. If I have to choose if I was going to be a basic scientist all my life, I could not see myself not being clinical, and that's one of the factors that helped me move. Research trials, you can do them still in private, and the outcome of that can benefit your private practice. And transplant center, they're siloed in academia. In the hospital, they're more flat, and you can have private transplant like Dr. Mitchell. And the last I say, the grass is not greener, so really enjoy the grass you're on. And it is the same green. It's just a different type, and I hope you find the right type for you. Thank you.

community hepatologist

practice settings

hospital acquisitions

academic vs non-academic settings

contract negotiation