All right, well, thank you for hanging in with us. We have one more talk by Dr. Paul from the University of Chicago about her life as an academic hepatologist. Good afternoon, everyone. Thanks to Michelle and Aparna for inviting me. So these are my disclosures. So I'm going to tell you a little bit about, like, as everyone else did, kind of where I came from. It'll frame it a bit. So I actually grew up in New York, but came to Boston for college and lived here for 16 years and just moved three years ago. So I did my residency at Mass General Hospital, did my GI fellowship, and actually got a master's in clinical science and translational science at Tufts and through the Sackler School. I actually did four years of GI fellowship. I did the exact opposite of what Oren was talking about. I did the long track. But I also had my son during that year, so it helped. And then I went back to MGH to do my transplant hepatology here. So then I was trying to look for a job. And no one really tells you how to do this. And so I knew I wanted to do academic medicine. It's really hard to do transplant in the community, but it is possible. And I did a private practice rotation and GI fellowship. And I knew they worked incredibly hard, but it just wasn't for me. Location was incredibly important. We wanted to be in a big city. Boston was a possibility. And my wife and I tried to find the perfect location for us. So how did I find my job at University of Chicago? A lot of it was word of mouth. I emailed a lot of chairs to see if there was a position open. I actually Google searched transplant hepatology jobs, believe it or not. And that's how I came across the U of C job. And so there was an application, and I had never really been to Chicago. I did know a few of the physicians here are at U of C. So I applied and went through the interview process. And then really, the package that they put together was really great. I really loved the people there, so I accepted the job. When Dr. Brown was talking about contracts, so the biggest thing in my contract was that I wanted a window office. That was one of the biggest things that I wanted. And a dual monitor, which I got. So in terms of the job process, it's really, I can't highlight and stress the importance of how important it is for someone to review your contract. I, and as many people as you want, you're not bothering them. They're your mentors, they're there, they've been there. Because everyone's gonna add something different, and I really didn't do this as much as I should have. The other thing I'll say is don't burn bridges. You never know where your career is gonna go back to. Or you have some family event, and you have to go back to the city you were in. You really don't want to be that person that doesn't want to hire you, because you did something awful at your last place. The other thing is, if you can, try and take some time before starting. I had the ability to take three months off. It was my first break since the summer before med school. And so I really enjoyed that time to kind of discover who I was again. So this is a typical week. It's very color coordinated. So I'll kind of go through what I do in general. So typically I do five to six clinical sessions, mostly clinic. I do a lot of general hepatology, so three to four half days. I am in the fatty liver clinic as well, so I have one day of that. I have a transplant clinic where I see pre and post. And I occasionally will cover the liver tumor clinic. I do a half day of endoscopy a month. I was doing more, but being on the south side of Chicago, I had a lot of no-shows and open access, and it was really hurting my RVU. So I decided to cut back, because I was being more effective in clinic. And I also have an outreach clinic downtown. In terms of conferences, we also have conferences. So PATH Conference, Liver Tumor Conference, and then Patient Selection as well. And so this is, I mean, if you think about it, at least for Liver Tumor Conference and Patient Selection, it's a sizable chunk of our Thursday afternoon. And you're not necessarily, I have clinic all morning Thursday, and I have a ton of notes to write, and I really can't, because I'm in Selection and Radiology Conference. In terms of service time, so I do ten weeks of inpatient service time. We actually just started covering the weekends as well, so I work ten weekends. We have a liver hospital service and a liver consult service, we cover them both. It includes pre and post transplant services, consults as well. The typical census, so anywhere between 15 to 30 patients. There's a fellow, some rotating house staff, and just recently we stopped taking overnight and weekend endoscopy call. Which is, for me, when I heard the words food impaction, like I had palpitations, it was just not something I could do anymore. So other things, I try and continue to do research. I do run some clinical trials in the PI with industry sponsored trials. I do projects with fellows and house staff. I do teach, I do clinical didactics, noon conference, morning report, which I really enjoy. And I'm also leading a Project ECHO. So Project ECHO is basically for obesity. So the obesity comes in because my interest in fatty liver led me to become board certified in obesity medicine. Because as we all know, the treatment for fatty liver is to lose weight. So that's how I kind of incorporate that. So I'm actually doing a Project ECHO series for obesity for the university and the community providers. So I just wanted to, I mean, that's kind of like my typical day, but I wanted to kind of go through things. It's been three and a half years since I became an attending. And I think the things I've learned since, so your section chief is really important. I have David Rubin, who is a very, just a very great person. And so it's really important to have honest conversations and expectations up front. You wanna talk in the first year what you're doing, what you're expected to do. Not in year five when they're talking about promotion and they're all of a sudden like, well, you didn't do X, Y, Z, and now you're gonna be like an assistant for another ten years. I think the other thing that I learned is your colleagues that you're gonna work with are really important. And I found five other people that I can go to help without any reservations. I actually won my first colonoscopy that I did by myself. I was an 80-year-old woman who had had a bunch of surgeries. I got stuck in the sigmoid. I owned it. Someone came in and helped me. And it was literally my first, I mean, I think the endoscopy nurses were like, who did we hire? She can't get even out of the sigmoid. So I really won the lottery. And I think, especially my hepatology colleagues are very, very, they're awesome people, and they're my friends as well. I think mentorship, as Elliot said, is really important, but sometimes hard to find. So really try and identify people that can help achieve your goals. That was an excellent talk. And then sometimes even reach outside of your institution. Especially now with technology, we can do a lot. It may be important to find a niche, not necessarily, but, and if you do find a niche, it may change. So Tufts, as you guys know, is located in Chinatown. So I did a ton of hepatitis B research. My specialty was in reactivation, studying reactivation. And when I moved to Chicago, especially at U of C, where we are, there just isn't a lot of hep B patients. And so it was really hard to study that. But there was a lot of fatty liver, and there's a lot of obesity, as it is everywhere. And so that's where my interest in fatty liver and obesity and nutrition went through. And I had a really supportive chief to let me take the time to become certified in obesity medicine, cuz it took a while. I think being on committees are really helpful through organizations, so get involved in societies. Networking and word of mouth, I think, goes a long way, especially when you're looking for a job. And consider starting early. Most of the SIGs and committees have a spot for trainees. And ask your mentor to put you on one. I mean, that's what they're there for. And the other thing I learned after three and a half years is that I truly love academic hepatology. Like, this is what I was meant to do. When I first got there, there was a huge wait list for general GI, so they made all the hepatologists do two sessions of general GI. And I had a patient that had likely IBS, but that patient scared me more than the Melda 40 sitting in the ICU bleeding, cuz I'd rather take care of that patient. And then I knew, this is the right decision. So there is a light at the end of the tunnel, especially for the residents here, the emerging liver scholars. Training is hard, but you get through it, and it's a lot better on the other side. So things I struggle with, so every institution is different. And some institutions, you're not RVU-based, you're just salaried, especially in transplant. For us, we're kind of a hybrid, but they say they don't matter, but then they really do, and every institution is different. So I try and keep up with my RVUs, and this is a picture. So where U of C's tagline is at the forefront, but they still print out all of our schedules for clinic. So this was one day, I had a full day clinic, and the list was taller than me. That's Andrew Aronson, one of our hepatologists. So clearly, I mean, I try and double book it, cuz again, there are a lot of no-shows. You kind of have to figure that out. I think trying to find time to do research is really challenging. Trying to find funding for protected time is challenging, but sometimes you just have to do it. And then work-life balance, and Monica gave an excellent talk on work-life balance. I think it's different for everybody. For me, it's my family and doing things that I love outside of medicine. So I love to cook, watching TV, Food Network is a huge thing. My five-year-old watches Food Network and wants to be Bobby Flay. Craft beers, we're in Boston, so my favorite restaurant in Boston is Pico. It's a pizza ice cream company, so they make their own pizza, their own ice cream, and they have the best craft beer selection. It's close by, I definitely recommend it. It gets really busy, though. And then biking. And so I have balance most days, not often. I still have a five-year-old. But I have a Peloton. My username is Liver Lover, which is so dorky, but I just love it so much. It was kind of my gift to myself when I became an attending. And I use it every morning at five in the morning. I wake up, I exercise, and if I don't do that, everyone on my team knows that there's something off. My family will know that I haven't worked out that day. And then this is my family. So that's my five-year-old, Raj, my wife, Kathy, and our 10-year-old dog, Milo. So I hope that kind of helped, and that's all I have. We have just a few minutes for questions. Oren, Monica, if you guys want to come up too. I don't think that Elliot and Dr. Brown are here. While they're coming up, are there questions from the audience that we can take for anyone that presented today? Yes, please, go ahead. Hello, my name is Mahmoud Bayoumi. I'm a third-year resident at the University of Tennessee. And I'm also a Master of Public Health Epidemiology candidate in the same university. I'm also applying for GI, so I like that there is a light at the end of the tunnel. The process can be very blinding. So my question is about the pilot track. So you did mention that a decreased amount of training, which is good, but there is a concern that there are some stuff that you mess up on, like electives and some things that, like, for example, some programs will give up motility and other stuff. One of the ABIM requirement is for you to have five months of hepatology training during your general GI. Is that something that we can give up if we do the pilot track? So for the pilot, we wanted some hepatology to be part of the first two years of GI to make sure that that was really, you know, you wanted to do hepatology as a career and that you were a good fit for the pilot program. And then we thought that two or three months of that could be part of your transplant hepatology year. In creating the new requirements for the certified pathway, ABIM wouldn't bend on this. They said that 18 months of clinical work has to be in GI and 12 months has to be in hepatology. But they didn't go further to define what those 18 months are. So in essence, I think you're going to end up with a lot more time in hepatology in the dual pathway, but you still have to do, you know, 30 months of clinical time. So it does decrease the amount of time of lactose for sure. And again, you know, based on what I gave in my talk, I think if you want to spend time in your fellowship doing other things and there's a lot of merit to doing that, then you should probably spend an extra year in GI and then go on to hepatology. Thank you. Other questions from the audience? Hi, I'm Brian Horwich. I'm a second year resident at University of Southern California. I have a question for the panelists that kind of did the day in the life snapshots. Was there anything about each of your individual sort of career paths that you went down that you found to be sort of a pleasant surprise that maybe an added benefit that you weren't expecting from going down the route? I know some of you touched on it a little bit, but anything like that comes to mind that maybe didn't get highlighted? I mean, for me it was, I never thought in a million years I would be board certified in obesity medicine. That's just crazy to me. Like, I wanted to be a hepatologist, but then when you start studying a disease process like fatty liver, I think for me that was the biggest thing. And that's kind of launched into a different part of my career that I never expected to go down. This is going to sound very weird given the funding climate or what people imagine it to be, but the pleasant surprise for me was that the writing of the grants was not as onerous as I had imagined it to be. Because if you're in an institution that has a track record of writing, has people who are willing to share, and you can copy and paste sections, it's not actually as onerous as you may imagine, if you enjoy writing. For me, the most surprising thing was the people that I met along the way. It was the people that I used to read about, what the research is, and now I found myself being invited, giving talks in their labs. So, that is what happens. It takes time, but it's very surprising. I'll say that I never thought I'll do what I'm doing right now. I'd never really even thought about that I would be looking for a job that I have right now. I even turned down the job, as I alluded to, but then I reached out to people I trust, I consider mentors, and I'm glad I did. So, what I'm saying is that pleasant surprises come as opportunities. I think it's fair to stop and think and ask, and then see if you wanna change gears. Thank you. Amad Alkadour, first-year GI fellow, Augusta University in Augusta, Georgia. Our program, unfortunately, does not have any hepatologists, nor do we have a hepatology program, transplant or otherwise. We do, obviously, see a lot of liver patients. Prior to my fellowship, I did do a one-year hepatology fellowship at Temple that's non-accredited, which is what kind of put me on the path towards hepatology, and I'm glad I did. I'm on the path towards hepatology. But my question to the panel is, how important is it for me to do another year in transplant hepatology to get board-eligible after my GI fellowship, or do I just focus on attending courses and building up my resume, knowing that our program does not have that much hepatology expertise, so I'm not gonna gain, other than seeing patients in clinic and self-reading, of course, build that much experience? First, you may not necessarily have to do an extra year. I don't know if you've talked to ABIM, but sometimes they'll give credit for your hepatology or toward your GI training. I spoke to my program director at Temple, and he said that, well, I spoke to my section chief, and he's already trying to get me credit for it, and so far that's been unsuccessful. And I spoke to my chief of hepatology at Temple, who said because of the low volume of transplants that we had during the year that I was a fellow, he thinks there's a low chance that I can become board-eligible when I do graduate, but he's gonna try to write me a letter to get me that exception. So we're gonna work on that, obviously, but I'm just thinking of plan B. Yeah, no, just to be clear, if you don't get credit for transplant hepatology for the year you already did, you may be able to get credit for that year toward GI. No, I know, I'm working on both fronts. Okay, good, but I think if you wanna be certified in transplant hepatology, you're gonna have to do another fellowship, whether that's another year or not, I guess you'll have to figure out. That's a really tough one, because if you've already got the training, if you feel like you're competent to be a transplant hepatologist, you've already got the training, then you may not gain much other than the certification itself, and I think that's a personal decision that you'll have to make. Are you willing to put in another year just for that piece of paper? I think there are some advantages to being certified, as I point out in my talk, but I think, more importantly, it's what you can do, the things that you can bring to the institution you're working at, and if you've got the experience, then the certification may not end up mattering. Dr. Kotech, in a setting like your hospital, how important do you think that is? For employment, it's not required. And what about for contract negotiations and salary? No, it's not. Actually, we have one who is not. Okay. Thank you. Hi, I'm B, Pirapadit. I'm a transplant hepatology fellow at University of Chicago. I'm looking for job right now, and I'm interviewing many place. I have a specific question that I would like to ask for your comment. During my interview, I come across institution that have a transplant center that has a transplant kind of like model, like I'm talking about the admin part, transplant instructor or head of transplant and go to transplant, and there's a conventional way of a surgery, GI, kind of like kind of work together. I kind of want to hear your thought about that and how the pros and cons and how would that affect your, like at least kind of like at least you're gonna get paid from transplant center versus kind of like transplant with GI or it's kind of confusing to me. At the end, I like hepatology. I like taking care of patient, but I kind of want to know, would that affect me at all? Would that even have to be something I should think about or as long as the teamwork is great, the colleague is great, that's fine. I feel like we could have had this conversation yesterday. So I think it's a good question. So I don't think it matters as much in terms of, I think there are a few things. So one would be who's gonna take call. I mean, just like practicality, right? So if you're not sharing call with your GI colleagues, is that what you're asking me or? I'm more asking about. Pay? Not pay, about how would that affect your job. If you're employed by transplant versus GI? From the instruction organization standpoint. Transplant center versus the conventional way of surgery and GI. Am I making? Like? Because I went from an academic center that had, I was in the GI department and now I'm at a transplant center where I'm in a transplant department. My boss is a surgeon and the department is hepatologist, nephrologist, transplant surgeons. Is that what you're talking about? The distinction there? Yes, exactly. Yeah, so I left the academic setting in part because I felt like I was constantly trying to justify my existence and not getting any of the credit for the transplant department. So being in GI, it was almost like the surgeons were getting all the credit for transplants and we were just being measured as if we were a gastroenterologist but not doing as many procedures. So I found that to be very stressful. And I also was being pushed into more RVUs and more clinical work. And I felt like, why am I in an academic institution if that's what I have to do? So I went to this other department that, this other model where we're all in one department. I felt like we're gonna have, we're all on the same page. The surgeon wants me to be seeing transplant patients and the volume of the program is gonna be what I'm measured on. And that worked for a little while but this is really not really gonna answer your question but our hospital has some financial problems. The model didn't work. But in general, I think that it is easier in a transplant model to sort of justify what you're doing if you're seeing transplant patients. I was not expected to do endoscopy. I was not expected to do any general GI call. My goal was to grow the transplant program and that was pretty clear. May I comment? So I'm in the, I follow the same track as Oren. I had a different path, how I ended up there. But I have to tell you that who owns the money owns what you do in a sense that yeah, money is not important in a sense that you have to decide and you're absolutely correct. Collegiality, what the center has. But nevertheless, whoever pays your salary is gonna own your schedule in a sense. So if it's the GI division, then it's the GI chief because transplant surgery in an academic center usually pays the GI chief. The GI chief gets the money and they allocate the money, not necessarily, I mean they pay your salary, et cetera, et cetera. But if they are at the crunch, they're gonna come to you as a GI faculty and I think that's fair. In a transplant center, obviously as Oren said, it is the benefit of the whole center. But the specifics of each center, I think it has to be studied by you basically and asking some people who you trust outside what they think about that landscape. I hope I answered so much of your question. Because the other thing I would add is that I think every institution is very different. So I can tell you when I first signed on, I was hired by GI. Right now I am, so I was hired and paid by GI, but right now I am salaried by the Transplant Institute at U of C, but all my promotions and academic things still go through GI. So if that makes, it's so confusing. So I think it just depends on the institution. Thank you. I think we maybe have time for two. I see one question, two questions. Two last questions and then the academic debates are at 4.30, so I wanna make sure that you all get there. Hi, my name is Giselle Mahara. I'm a resident at the University of Virginia. I applied to GI this year. We talked a lot about contracts and money and how that doesn't matter. I did have a question specifically for the female hepatologist. How do you navigate, it looks like all the surveys recently do still acknowledge the pay gap, so specifically at the beginning, where really any kind of money they're offering looks amazing compared to the fellowship salary. How do you navigate that to make sure that you are being valued as much as your male counterparts? I can start. This question was for the female panelists, right? Okay, so I guess I qualify. I was really fortunate that at the time that I received my draft of my contract, I was working with my PI and he insisted on, he's outside of my division, and he insisted on seeing it and reviewing it and he said, don't sign this, send it back. And here are the things that were missing and really, actually, very critical things turned out that I hadn't noticed. So I would say, don't sign the first version. And give it to someone who is more senior, who you think has probably had success with their own negotiation and have them mark it up. You can also work with a lawyer if you can afford or if you have a friend who does that kind of work. But I do think it's something we're not trained to do and I would caution against assuming that your institution has your best interests. They have, I think, first and foremost, financial interests in mind and that makes sense because they have to make sure that the division runs and the patients are taken care of. So yeah, just show it to someone. And so we marked it up and then the next version was much more suitable. The other thing I would mention is that there are resources, I think there was a resource slide, I didn't get a chance to see all the listings that were on it, but hopefully the AAMC prints every year what the salary is or the range of salaries for every faculty, every kind of faculty, whether you're clinical or clinical researcher and the different ranks. And you can see the percentiles according to your location. You do have to pay to get access to that but there's someone on your campus who has access, probably someone in the dean's office, maybe even, I wouldn't go to your division chief, but someone who has access to it and you can review that so that you know ahead of time what the proper range should be and you ask for more than what you think you should be getting and hopefully you end up with something near where it should be. I'll just like, just to add one thing to that. There's no, it may be impolite to kind of talk about how much money you make but at the same time it's really helpful to know that information and it was very critical to me as a junior faculty when people who recently hired as junior faculty would openly share that with me and so I do that when people come and talk with me. It is what it is and I'm happy to tell them how much money I make and that I just think is helpful. So hopefully you can find people that are kind of willing to talk and will help put what you're offered into context. Okay, last question. Hi, I'm Ghazli, I'm a third year resident at Henry Ford Hospital, Detroit, Michigan. We're kind of talking about, I'm interested in academic GI, I'm applying for GI fellowship this year. My question is pretty early on in the career I was told as a medical student that you kind of paint your own career pathway and you paint your own research track, what you want to do if in future you want to be an academician. So my question is that, Dr. Paul, you mentioned that you transitioned from some research background, hepatitis B to NAPLD. How was that, how did that play a role in your job opportunities? Was that acceptable, was that, you know, how did the community take that transition from one research background, maybe like expertise in one topic to another? I mean, they were very open. I think it was not so much the topic, it was the set of skills I had. Because I got my master's and I knew how to use, can you work with large databases, I knew basic stats, I could do my own thing. So I think it was more the skill set that you have that they valued more than just the topic. Because then I can apply that same skill set to fatty liver or whatever. And so I think one thing was that, and I think the second thing was that when, there was a mentor there that does, Dr. Charlton does fatty liver work. And so I was junior faculty, he's senior faculty, it just made sense. And it's so common, because I really wanted to study autoimmune and PSC and PBC, but it's so hard to study those diseases because they're so rare. But fatty liver is definitely not rare. And so it was just an opportunity to kind of fill my lap. So what I'm hearing is it's okay to transition from research topics to another? I think so, yeah. Yeah, any other opinions? You're welcome. I would just say you have to tell a clear story. So I don't think anyone up here would say that where you are today was predicted when you were a medical student. I mean, I showed you my meandering. But as you're applying to programs, you do still have to make a coherent story, even if it wasn't exactly coherent as you were going through it, if that makes sense. So if there are these themes that run through, a technique that you use that you're able to apply in these various areas or something, it kind of does need to create a story, if you will. Thank you. Great, thank you very much. And thank you for all the panelists again.

Dr. Paul

University of Chicago

academic hepatologist

mentorship

contract negotiation

work-life balance

research interests