I'd like to thank the organizers for once again, inviting me to speak at their career development workshop on fellowship training in hepatology in the time of COVID-19. I'm Oren Fix, the medical director of the liver transplant program at Swedish Medical Center in Seattle, Washington. I have no relevant financial disclosures. There are currently two formal pathways for hepatology certification in the United States. There's the standard pathway or three plus one, because you have to do three years of gastroenterology fellowship, followed by the ABIM certification exam in GI, and then an additional year of transplant hepatology fellowship, followed by the ABIM certification exam in transplant hepatology. There is now a new dual certification pathway, formerly known as the pilot, which is three years of combined GI and transplant hepatology training. And at the end of three years, you're eligible to take the GI exam. And if you pass the GI exam, you can then take the transplant hepatology exam without an additional year of hepatology training. There are many hepatology career paths. You're gonna hear from people during this workshop about each of these. Some are clinically focused, some research focused, some academic, some community-based. But I believe that all of these hepatology career paths require some form of specialized training beyond gastroenterology. And just looking at the GI program requirements, you can see that the educational program in gastroenterology must be 36 months in length, but only a minimum of 18 months must be devoted to clinical experience. And of those 18 months, five months should be hepatology. So what do we learn from these requirements? First of all, that hepatology is part of the training and the competency of a gastroenterologist. But there's also a lot of time, 18 months that are not specified by ACGME. And that leaves a lot of room for you and your program to tailor your experience to achieving competence in GI, but also in focusing on your career interests. That might be research, that might be endoscopy, that might be motility, and it could also be hepatology. So what is a hepatologist? Is a hepatologist different from a gastroenterologist who sees mostly liver patients? Is a hepatologist different from a transplant hepatologist? I think these are important distinctions. We made a case in 2006 for the creation of a new specialty now called transplant hepatology, because we were able to show with workforce data that hepatologists have a distinct skill set, a distinct set of expertise and competence beyond the general gastroenterologist. And in fact, many general gastroenterologists refer their complex liver patients to hepatologists, either because of lack of experience or lack of interest in taking care of these types of patients. So I don't think hepatologists is simply a gastroenterologist who sees mostly liver patients, although those physicians are really important. Gastroenterologists who see a lot of liver patients are really important for the hepatology workforce and meeting the needs of our liver disease patients, which is only growing. I think a hepatologist is not really different from a transplant hepatologist. I think it's just a semantic issue. And I think it's done a bit of a disservice to our specialty. So what do I mean by that? Well, transplant hepatology to a lot of people means another year of training. It means additional certification that you may not see the value of that. You may not wanna work in an academic institution. You may not wanna work in a transplant program. So you may not see the need for transplant hepatology training per se beyond hepatology training. And personally, I think we've done a disservice to our specialty by naming it transplant hepatology. It was originally developed to differentiate us from a gastroenterologist who also sees liver patients. And it was really chosen to assuage the GI community that we were not interested in taking hepatology away from GI and separating from GI. And to this day, transplant hepatology is still a subspecialty of gastroenterology. I don't think there's a huge appetite to decouple hepatology or hepatology training from GI. And I think there are some practical and logistical reasons for that. But I also think it was relatively easy at the time to define the distinction between gastroenterology and hepatology along the lines of transplant. But really, our specialty is much more than transplant. And I don't think our training can practically avoid transplant if you wanna be able to manage the full spectrum of liver disease. And it still doesn't mean that you have to train, or excuse me, you have to practice in a transplant program or an academic institution, but it also doesn't mean you should steer away from the additional training if you want a clinically focused non-academic or non-transplant career. So again, I think transplant hepatology differentiates especially trained hepatologists from the gastroenterologists who also sees liver patients. And again, I think hepatology remains a subspecialty of gastroenterology. But I think we should take a cue from our cardiology colleagues who've named one of their many subspecialties, advanced heart failure and transplant cardiology, because really what we do is advanced liver disease and transplant hepatology. And from my practice and a lot of my colleagues who are transplant hepatologists, I would say the majority of our practice is advanced liver disease and not liver transplant. Does certification matter? I think that's a valid question. There are some advantages to the additional training and certification. It demonstrates your expertise to employers, colleagues, patients, and the public. It may command a higher salary depending on the job and location. It may open the door to leadership positions, for example, medical director of a liver transplant program or a fellowship director of a transplant hepatology program. And it may actually give you a competitive advantage in the job market. There are lots of hepatology jobs, but they're not uniformly distributed throughout the country. And some areas are saturated. And in those areas, having certification may actually give you the leg up that you need to get that job. Disadvantages to a certification. Well, in some cases, it does require an additional year of training, but as I've shown with the three-year dual certification pathway, that's not necessarily true. It does require an additional certification exam, but it may not require additional MOC exams. You can maintain your transplant hepatology certification without having to take MOC exams in internal medicine or gastroenterology. And that really depends on your interests, your practice, and also the requirements of your hospital or practice. There is a predicted workforce deficit in hepatology, which essentially lends us some job security if you're interested in this specialty. We just finished a workforce study that shows that we may have a 2,000 FTE deficit in the next 10 or 15 years. And this is because of the growing number of patients with liver disease and also the dwindling hepatology workforce, largely due to a lot of retiring physicians in the next 10 years. So I think that there's gonna be job security. Again, not all the jobs are uniformly distributed and it may be harder to find jobs in areas that are desirable to live, metropolitan areas, for example, but that doesn't mean those jobs do not frequently become available. I think that hepatology is a resilient specialty, and you can see this from COVID-19. Unlike our GI colleagues that relied on procedures and there was a distinct pause in elective procedures when the pandemic hit, hepatology is largely a clinic-based practice. And we were able to pivot, a lot of practices and hospitals were able to pivot their hepatology practices from in-person visits to telemedicine visits. You can see this example here at University of Pennsylvania where there was a dip initially, but very quickly they were back to almost the same volume of clinic visits as they were before the pandemic, only mostly virtual visits as opposed to in-person visits. And the same goes for liver transplantation. Although elective surgeries were put on hold at the beginning of the pandemic, liver transplantation was very clearly not an elective procedure, but an urgent procedure. And there was a slight dip at the beginning, but that very quickly rebounded and we're back to pre-COVID volumes of liver transplantation in the United States. So I think all of this shows you that our specialty is resilient and there's job security. It's reasonable to ask if four years of training is necessary, especially now that there's a three-year training option. The advantages to that additional year, some people may need more time to develop competence in GI or hepatology. Additionally, your experience before independence is not to be looked at lightly. I think that even though we're focused away from time-based measures of competence and looking more at outcomes-based measures, I still think the time and experience is valuable, especially in the protective environment of a training program. And also that additional year will give you time to focus on other interests, whether it's hepatology or research or another degree, for example. The disadvantages to that additional year is time away from your career interests if you're doing three years of GI and then a year of hepatology and you wanna be a hepatologist, especially a clinical hepatologist. And it's a potential deterrent to additional training and certification in hepatology. We recognize that that additional year was a deterrent. That's part of the reason why the pilot program started in 2012 and eventually became a permanent pathway. So what is this pilot program that I've been talking about? In case you're not aware, we've been doing this pilot program since 2012. It finished last year with a total of 91 fellows who went through the program. We like to say that we saved 91 years of training for the group. And we did surveys of graduates after both standard training and the pilot program and found really no differences in a variety of domains, including competence, in the three years or the four years of training. And when you look at board pass rates, every pilot fellow took and passed the GI and transplant hepatology exam, which compares favorably to the rate of first-time takers, even though the pass rates are quite high across the board in general. So all of this was favorable data for the EBIM to make a decision to turn this pilot into a permanent training pathway. That was approved in 2019, and the first class is currently underway of this academic year. Training has to be completed at the same institution. You can't transfer to get your transplant hepatology training. You can't go back and claim that you met these requirements if you're not doing it prospectively after it was approved. And it's, I think, ideal for those who are interested in a clinically focused career, because it really is three years of pretty heavy clinical focus, not a lot of time for elective, but there is time for electives and for scholarly activity. So now I wanna get into sort of the practical approach to searching for programs and applying for them. I think one of the first places to look to find all the programs that are available is the ACGME website. And if you go to their homepage, you'll find the institution and program finder in the upper right. That'll bring you to this list of possible reports. And if you pick lists of programs by specialty, you've got a dropdown list where you can pick transplant hepatology or gastroenterology. That'll give you a PDF of all the available accredited programs and their contact information. The application process is variable in hepatology because there's no match, but in general, most programs start interviewing at about 18 months before the start of training. So if you're interested in training in 2022 and you're watching this video during the liver meeting in November, you really should be applying for programs and starting to interview about now. This is variable. Some programs do it sooner, some later. In COVID times, the interviews are all virtual. We'll see if that changes in the future. In addition to the ACGME website, I would look at individual program websites because like I said, every program has a different timeline, a different application. I would contact programs individually to get that information. In terms of selecting programs and contacting programs, I think you should use your program directors and mentors. Hepatology is a very small field. And so we know each other and it's really helpful to contact your program directors and mentors to help you to make those contacts to programs that you're not familiar with. Every program is gonna want a CV, letters of recommendation and a personal statement, and many will want procedure logs and transcripts. In terms of choosing a program, I think there are a lot of factors to consider. Geography is important. It'll help you to narrow down your focus, especially if you're constrained because of family or because of just simply a desire to live in a particular part of the country. Mentorship is important, whether that's research mentorship or clinical mentorship. Your research interest, you wanna go to a program that is strong in that area of focus and is gonna support your research interest. You might wanna consider training in a city that you wanna practice. A lot of people stay in not just the program that they train in, but often in the city that they train in, but that's not certainly universal and not required. And then I would also make sure you inquire about the availability of a dual certification pathway because if you're interested in the three years of training, not every GI program is gonna offer that. You wanna ask about that during the interviews, if not sooner. And then I think transplant program size is a very important factor. Whether or not you're interested in a transplant career or working in a large transplant program, I think that choosing a program that has a large volume of transplants is important. You'll just get more exposure to a variety of pathology and experiences, and it'll give you just that much more confidence in what you'll see when you get out and practice. So I think the key takeaways from my talk are that hepatology requires specialized training and may require an additional year of training beyond GI fellowship. I think transplant hepatology, at least as the name of our specialty, should be changed to better reflect what hepatologists do and to clear up any confusion about what the training entails. A transplant training is needed to develop the expertise in the full spectrum of liver disease. That doesn't mean that you have to go on to practice in a transplant program or in a transplant-centered practice. A transplant hepatology fellowship also encompasses training in advanced liver disease, and I think that's what's needed to manage the variety of liver disease, not only in academic centers, but also out in the community. Transplant hepatology fellowship is important whether or not you're interested in a transplant-focused career. There are two pathways to transplant hepatology certification, the standard fourth-year fellowship and the dual certification pathway formerly known as the pilot. Those with a clinical hepatology career interest may prefer the dual certification pathway, and those with an academic or research-focused career interest should use that third year of GI fellowship to develop the necessary skills for their career before going on to additional hepatology training. With that, I'll close, and I thank you very much for your attention. Hello. My name is Gautam Reddy, and I'll be discussing maximizing your training during COVID-19 for this year's ASLD Career Development Workshop. I am currently an associate professor of medicine at the University of Chicago. I serve as the associate session chief for clinical operations. These are my disclosures. The most relevant disclosure is I am the former GI program director at the University of Chicago up until June of 2020. Prior to that, I was a transplant hepatology program director. It is worth pointing out that I am delivering these remarks through the lens of a GI program director. These are my financial relationships, although none of these financial relationships are relevant to today's. This is an overview of what I'll be discussing today. I'll start with reviewing the COVID-19 effects on training, and then move to how we modify training during COVID. A lot of these remarks come from my discussions with program directors during the peak of COVID, as well as input from our fellows, and certainly what we did at our institution. I think a lot of what we did at our institution was done all over the country. Finally, we'll finish by finding a fellowship during COVID. It is worth pointing out that there are a lot of different levels of learners listening to this talk, ranging from medical students to residents, to fellows and beyond. There's perhaps surgeons as well as pediatricians, as well as internists listening to this. I do wanna give a thanks to my fellows for helping me to put this together. As most people know, COVID-19 caught everyone unprepared. The initial response was to empty hospitals and clinics across the country to prepare for the onslaught of COVID-19 patients. There were variable effects for training depending on geography. In some parts of the country, especially in the Northeast, residents and fellows were redeployed to take care of COVID patients. This limited their exposure to clinical GI and hepatology. It's also worth pointing out since elective cases and clinics were canceled, there were very few patients to actually learn from. There was limited access to mentorship due to people being very busy. And in most cases, national conferences were canceled, taking away the opportunity for networking and learning more about our profession. The immediate reaction across the country was to cancel live clinics and elective procedures. There was very little endoscopy being done really to conserve PPE and limit exposure. One of the byproducts was this was very little volume to learn to do endoscopy. In this survey study done from fellows across the world, including nearly 800 fellows across 63 countries, 94% of the respondents reported a reduction in case volume with the mean reduction total procedures being 99%. Nearly three quarters of the respondents were concerned training would be prolonged and there was a lot of anxiety and burnout reported. Inpatient volumes across the country also dropped. At our institution, anyone with COVID that had a GI or a liver issue was dealt with by the faculty and not the trainee. So what did we do about training? And this is more the University of Chicago experience. We completely blew up our system of training. We moved from four-week blocks to two-week blocks. We collapsed services because there were fewer patients and we canceled all elective procedures and rotations. This created a fairly robust backup plan for people who may fall sick or have to be redeployed. And we instituted what one of my fellows referred to as a massive didactic surge. All of our didactics went online by Zoom. We generally have three to four teaching sessions per week and we actually added two more during COVID which included a case-based endoscopy session run by our interventional gastroenterologist. And we also added a weekly journal club to review all the new data coming out about COVID-19. Because there was more time initially, a lot of our didactics became multidisciplinary with radiologists, pathologists, nurse practitioners joining us. We often had people that were no longer with us such as our alumni or other faculty from across the country joining our teaching sessions. We used the ACG universe to come up with a plan for individualized learning based on weaknesses identified in our in-service exam. And we encourage a lot of self-directed learning from the society websites as well as social media. And I have a slide to review that a little closer. After about two weeks, we were able to get telemedicine up and running for both inpatient and outpatients. We very quickly had fellows involved with some telemedicine although it is somewhat clunky, it has improved. There was more time for scholarly pursuits and a lot of our fellows and faculty took advantage of this time. Stress management was very important for our faculty. Both myself and my section chief spent a lot of time making sure our fellows and faculty were doing okay with a lot of check-ins. We established a weekly social hour including our alumni by Zoom. We made sure all of our fellows had the wellness resources from our GME department. And we really wanted to establish a blame-free culture. We also instituted that faculty would cover general medicine before fellows. So this is a partial listing of some of the resources that we were able to use for self-directed learning. There's a lot of information on the societal websites targeted at trainees. For trainees, a great deal of this was available gratis. Social media has turned out to be a very interesting place to learn. I think a lot of people have some reservations about the somewhat unstructured learning that's available, but it is becoming more structured and the rigor has markedly improved. These are a list of things on social media that are actually quite good. I do want to point out the Liver Fellow Network. This was newly started during the pandemic. This is actually a website that has a lot of great liver learning on it. There is some oversight from some faculty, but this was purely started and run by GI and liver fellows from around the country. I'm particularly proud of this because a couple of our fellows, Prita Patel and Tom Corey, have been instrumental in getting this off the ground, and I would encourage you to take a look at that if you have a moment. As you can imagine, after a few weeks of looking at Netflix and lots of online lectures, our fellows were really itching to get back into the GI lab. By mid-May, we really started to have some inkling of a recovery. We had a better understanding of COVID by that point. We had more access to pre-procedure testing, and we were able to reprocess N95s to have an adequate supply of PPE. By late May, we were able to get the fellows back into the endoscopy lab, and we prioritized the third-year fellows for endoscopy. But really, by June, everyone had access to doing endoscopy, and we had good volumes by July. I think most places are back to nearly pre-pandemic patient volumes. I think it is worth going back and think about some of the silver linings that happened during COVID-19. The first was embracing telemedicine. I think a lot of people are still doing telemedicine around the country. The patients really like it. I think as we prepare this fall and winter for more COVID admissions, I think telemedicine will really stay with us going forward. Now, beyond next year, it's a little hard to know. It's still a little clunky, and it does need some work to make it easier to use for both patients and physicians. But hopefully, it is here to stay. Reimbursements beyond the next few months are also somewhat murky. Initially, during COVID, when it first started, there was a lot more time to teach, although that seems to have disappeared some. One of the silver linings for us was since everything went on Zoom, we were able to capture all of our didactic content online for later review. This is actually a requirement for the ACGME, and we now have the means to do it. And the final one is somewhat unique to us at the University of Chicago. For years, as the program director, I've been trying to convince my fellows that we needed a backup call system. They now see the wisdom of it, and we were able to institute one during COVID, and I think this will be continued going forward. So there are many residents sitting in the audience who are going through the application process right now, and for the first time, this has pretty much been completely virtual. It's unclear what's going to happen for the residents in the audience who want to apply for the next interview cycle. Some of this will be more germane for you, but I do think it's worth reviewing some of the challenges there are for applicants. The next slide will review the challenges for program directors. I would encourage you to read this paper by Rika Malapalli, who is a GI fellow at USC. She does a nice job outlining these issues, and these next two slides are adapted from her work. So some of the challenges of less time on GI and liver rotations. Hopefully that's better now, but it may go back down as we get more COVID this fall and winter, but certainly you should reach out to your GI leadership and ask to participate in the online didactics within the GI division at your institution. There was less protected research time during the onslaught of COVID. It's unclear if most places have given people back their protected research time. The other challenges are IRBs across the country are backed up with COVID-related issues, so trying to get an investigator-initiated study off the ground is a little bit difficult. I would suggest asking your faculty for help and focus on reviews and database research that may not need an IRB. Any abstracts you should have, you should really do your best to try to convert those to publications. Mock interviews can help you prepare for those that are unfamiliar with virtual interviews. Because people can't travel for interviews, it's really hard to assess a program or a city's culture, but I think most places have a much more robust website and social media presence because of COVID. You should certainly do your homework on the city online, looking at prices, cost of living, amenities, and take some time to identify people you might know in any given city or program and reach out to them for more information about the program. A lot of the applicants looking for jobs and looking for fellowships have noted the serendipitous benefit of not having to travel and spend less time actually traveling to do interviews, and that gives them more of an opportunity to interview at more places. Some of the challenges the program directors have this year that are much shorter timeline to review applications, and I think most places just sort of did it, dealt with it. Creating a new interview schedule and new format logistics was tricky. We spent more time training faculty how to do virtual interviews. We were able to increase the interview slots, and the online format really added some flexibility we've not had in the past. I think most programs made their online and social media presence more robust to showcase the faculty and the culture. This last one here, the loss of venue for candid conversations, I think many programs organized virtual meet and greets with fellows at our institution. A lot of our fellows gave out their private contact information to answer questions offline as well. What are some of the looming questions? Will a lockdown happen again? It's certainly possible depending on your geographic location and how much COVID you have. Is the playbook better? I think so. I think having access to pre-procedure testing and knowing more about COVID, hopefully we won't completely have to shut down like we did this past spring. What will a vaccine do for next year's interview process and match, and will there be interviews in person? I certainly hope so. That's a question that remains to be seen. Will training outcomes be affected? I don't think so. I still think we'll be able to adequately train people to be good at what they do when they leave. What does a post-graduation job search look like? Right now, it looks very much like what the residents are doing looking for fellowships. It seems to be all virtual. In some cases, if there's a lot of mutual interest after going through significant interviews, a fellow may want to go look at a job in person. I think that's a reasonable approach. These are the key takeaways. COVID-19 has impacted every facet of training. Be disciplined in seeking self-directed learning and ask for help, including clinical exposures, scholarly exposures, and jobs. I'd like to finish by thanking the organizers and the ASLD for allowing me to give this presentation. This is a talk about being a mentor to launch a research career. However, before I define that admittedly odd-sounding term, I want to tell you a little bit about where it came from. It came from Nielsen Gupta and the relationship that we had as co-fellows, where we learned an enthusiasm for each other's research, worked on each other's projects, taught each other stats, study design, and wrote papers, 20 in total, over the course of our fellowship in early faculty. And we wrote a couple years ago an article that essentially celebrated what we learned about rising the ladder together. We published it with a picture that summarizes what I'm going to tell you over the next 12 to 15 minutes. I want to walk you through each of these steps. But before we get there, I think we need to clarify a couple of key assumptions about mentorship. If we're going to build this concept of mentoring from the ground up, we first must have the same respect for everyone. The input or advice that you receive from a friend, co-resident, co-fellow is often equal, if not superior, to that which you can receive from a full professor. You must be open to collaboration, intending to say yes, within reason, to most of the opportunities that come your way. Because even as a middle author or playing a supporting role on a project, you will be exposed to new ideas, new methods that will inform your approach to the projects most closely connected to your inspiration and motivation. And you must hold that others' success is the same as your success, and that by working in a team, everyone can meet their stated goals. Of course, you need mentors to get there. But what I want to talk about today is the way that we define a mentor, how we conceive of the mentee-mentor relationship. That traditional view, that traditional view that holds that a mentor has specialized knowledge, that they're a senior professor who imparts that knowledge upon the mentee to help them grow, is unhelpful for at least two reasons. One is that it robs the mentee of agency, self-determination, and the responsibility to learn how to extract what they need from that mentor for their growth. And two, it's a gross oversimplification, because in fact, there's no such thing as one mentor for all purposes. And the reality is that in a field such as ours, we undergo a rapid metamorphosis, where on day zero, we hardly know what we're doing. And even within a matter of months to years, we're submitting our own independent grants. And the kind of person that knows what it's like to be in your shoes to get from step zero to one is unlikely to be the same person that knows what it's like to get from step two to three. And this creates demand for multiple mentors and mentoring relationships across the spectrum and condensed within a very short period of time. But unfortunately, there are functional limitations on this supply of mentors. I call this a mentorship desert. Even where mentors are numerically plentiful, there are structural limitations that prevent our access. For one, there's a tyranny of the RVU, whereby clinical responsibilities are increasingly pressured by administrators, and this renders time for mentoring activities less and less available. Two, the kind of person that you're exposed to in academic GI has been there and done that. But you, you need to get on base. You need to establish a track record. So the kind of products that will help you and are doable within the timeframe of residency or fellowship, they are not multi-center RCTs or creating your own knockout mouse. And unfortunately, not all mentors know how to help you at your earlier stage. They've long forgotten. Three, not all mentors are created equal. You gotta ask around. Find out their track record. How many people have had successful mentoring relationships with that given person? And what you'll find is that sometimes what you learn is no good. Finally, it's also true that not all mentees are created equal. Many a mentor has found themselves ghosted on the eve of a deadline for a review article that they only agreed to to help out that mentee. And with that broken heart, they are now less willing to open the door to the next potential mentee that would come their way. Because of these functional limitations, we must develop the skills within ourselves so that we can attract the best kind of helpful relationships and to avail ourselves of the opportunities when others are able to help us. We cannot do it alone, but we also cannot depend on others. And this philosophy, Sengupta and I call Menteering. The set of skills by which you learn to navigate the research system and become resourceful. The mentee is always curious, scanning the horizon for questions. And one of the places they find inspiration is by reading, reading constantly, looking critically at the methods for new ideas and searching the introduction, following the references back to the original publication. So that they understand what the gaps in the field really are. And they use these gaps to generate the specific questions that will allow them to make their own unique impact on the field. They do not ask for a project. They come up with an idea that gets them out of bed, gets them motivated to get it done. They seek collaboration from peers, as well as those higher up in the food chain. Constantly learning from others, asking what people did, how they did it, what went well for them and what didn't. And they benefit from others' success. They all love to hear what made things work. They love to be a part of projects that succeed. And when they fail, they embrace the opportunity to learn. Because from introspection comes knowledge and the power of knowing how best to phrase your question. What method one must use to get that paper, a full review at that journal, and so forth. Mentors view deadlines as the first and best opportunity to set a reputation as a doer. As someone who's dependable and someone who will never over-promise and under-deliver. Mentors make their questions clear. And there are two main mechanisms by which you can clarify your research question. The first is to write it out. If you're going to attract the input of a would-be mentor or co-menteer, you're going to need to think through things on your own at first. So describe the problem, the impact of that problem on the world, and why it matters, and why it's worth someone else's time. Describe the research that's been done and what hasn't been done. And what you'd like to address with a question that's testable, that's falsifiable, that's doable, with a data source that you understand, that's accessible. And it will allow you to answer your question. It could be a systematic review, a retrospective cohort study, or even a randomized trial. But you need to understand what kind of work is necessary to answer your testable question with a specific plan. A one-pager is a critical element in communicating your research concept. But another opportunity that is often presented to us, which is also incredibly useful, is simply giving a talk. We're often asked to give talks as residents, fellows, junior faculty, and this is an excellent opportunity for you to dive deeply into research, understand the gaps in that field, and to develop your questions and get immediate feedback from the senior clinicians and other peers in the room who will help you develop your question further. So, in my experience, when I was a second-year fellow, I was asked to give a talk on a controversy in hepatology. And I saw that people were pooh-poohing the frequent use of ammonia-level testing in the emergency room. So I figured, why don't I give my talk on ammonia levels so I can find out what the deal really was? And I gave a PowerPoint presentation where I outlined why the ammonia level may not be instructive for the given patient in front of you because of the confounding impact of other factors, including but not limited to cognitive reserve and the burden of inflammation in that moment. But I also learned that ammonia levels are treatable targets and they reflect homeostasis, sarcopenia, kidney disease, and comorbid bleeding. So I was able to present this topic and get immediate feedback on what was unclear and also what would be an interesting question for the literature. In order to attack that further, potentially publish my talk in an open forum, you need to build a team. So I got feedback from that conference and I was able to edit my PowerPoint. I actually published that PowerPoint in a matter of speaking a few years later on Twitter and got very nice feedback from the public. And also learned some other questions that relate to ammonia testing that would inform further research. But in the context of that original presentation, I found some friends that would be helpful and were interested in helping me write a review article. You can't write a paper on your own. People love the sound of their own voice. They can't see their own flaws. You need critical input. And I was able to get that from a resident friend and a co-fellow. And together we wrote a review article. We had a great time. And it's been cited nearly 100 times now. Venteers are also always curious. They're seeking to extend their research by creating a body of questions that build on top of one another. So if we found while writing that review that an ammonia level could reflect homeostasis, maybe it was a biomarker of survival. And this was a question that was posed to me by one of my co-fellows, pictured here, Dr. Vilas Patwardhan. So we thought, let's do a retrospective cohort study of all the patients who had an ammonia level tested in the emergency room and see what happened to them. So if you're planning on doing any project, your next step is to anticipate and overcome rate-limiting steps. And two of the most burdensome ones that we know are getting the IRB and knowing how to collect the data. For the IRB, the first thing that we did is we tracked down someone who just had a retrospective cohort study approved. And we took all the boilerplate language that the IRB needs to see and we simply copied and pasted it. And we took the review article that we were writing and we turned that into the introduction and largely the methods of the protocol. And within a matter of months, because we were able to get it done real quickly, we got our IRB approved. But once it's approved, you got to do the work. At a minimum, you need a team of people who will commit to spending time to going through those charts diligently. But when they open up that chart, you got to have an attack plan. You got to be organized so that you're making every second count. And the best way to organize your thoughts is to make shell tables. Ask the question of yourself, what do people want to know about your population? Sometimes when you're just starting out, it's hard to know what the field needs to know before you get that review back. So read other papers. Look at Table 1. Understand the kind of factors that need to be described for future multivariable analysis in Tables 2 and 3. So if you find things like the etiology of liver disease, MELD score, the presence of acute and chronic liver failure are important. And that means that when you open up that chart, that's precisely what you need to extract. The result for us was a paper that we were proud of. It showed that the ammonia level at presentation was associated with 90 day survival. And the author list is essentially a collection of all the friends that we made while getting advice and writing this paper over time. Mentors have fun while working in teams. Through these relationships where you're lifting all boats, everybody's getting something out of it, that you're making friends and you're building a research family that you can turn to time and time again. Sometimes you're literally building a family. And here's a picture of me submitting my K award so that you know a couple of things. One, you can have a work life balance. And two, it does require some ingenuity to get it all done. But to do that, you are creating, but when you do it, you are actually creating a research family and carving out time to create your real family. And for real families, we share, we give credit. It's time for me to conclude by thanking the people that have made the biggest impact on my career. At the bottom, it's people that may not have had a national representation or reputation at the time that you're doing the work, but they knew how to get things done and they had time and they were available to help. And together we grew into people that had a platform, but we needed to turn to others who had recently been through steps one and two. And those people were essential in helping us polish ourselves to get ready for the advice from the most senior clinicians. Looking back on all of this, it's amazing how far and how fast me and Neil came from the time that we were working together as co-fellows. And I know that I couldn't have done it without him. And for that reason, I hope that this talk was of value to you. Good afternoon, everyone. Thank you for joining me today to discuss a career in academic hepatology at this year's Career Development Workshop. My name is Alison Fox. I am an Associate Professor of Medicine at Columbia University, Vagalos College of Physicians and Surgeons in New York City. I have mainly a clinical practice where I take care of patients, both before and after liver transplantation, as well as general hepatology patients. I'm the Medical Director of the Inpatient Solid Organ Transplant Unit and the Medical Director of the Living Donor Program here at Columbia. I also have an educational role in the medical school. I'm the Course Director for the Second Year Medical Student Pathophysiology Course, and I'm an Associate Designated Institutional Official in the New York Presbyterian Graduate Medical Education Office. I have no disclosures for today's talk. So I would guess that the majority of you, by virtue of the fact that you are attending today's workshop, have an interest in hepatology and just need to figure out if it's the right field for you. I guess the easiest way to start thinking about this is to figure out what drew me to hepatology and see if I can use that example to explain to you guys why I think this field is wonderful and worthy of your training and attention. I think overarching themes for this are that there is such a breadth of clinical research and procedural interest that one can satisfy by pursuing a career in hepatology that it automatically stood out to me, even early on in my medical career as a student, as something that I would be extremely interested in. I can remember being a third-year medical student on the wards and rotating on the liver service and learning about liver disease, end-stage liver disease, liver transplantation. And what it really was was I was once sitting in a didactic lecture on hepatorenal syndrome and hearing about how these kidneys were so diseased in this person with end-stage liver disease. But then if you were to transplant this patient, the kidneys kind of came back to life. And it was all the liver disease that was impacting the kidneys really just drew me to the field. I was like, wow, the liver is so all-powerful that it can really affect so many organ systems when it is in failure. And I was immediately drawn to the breadth of clinical pathology that transplant hepatology got to see. You know, I very much enjoy rounding in the hospital and interacting with various different subspecialties. I'm somebody who really enjoys critical care medicine. And of course you get a lot of that in liver transplant practice. I enjoy cardiology, renal disease, pulmonary. And so, you know, transplant hepatology, because you do have all those offshoots and complications of end-stage liver disease, you really do get to kind of check a lot of boxes in terms of the exposure you'll get to other organ systems and the very pathology that you see in those organ systems because of liver disease. At the same time, I noticed that there was just this wonderful intellectual opportunity that was present in patients with taking care of patients with end-stage liver disease. And more importantly, the questions that one could ask. I very much see transplant hepatology is really lending itself to a research career as there are still so many unanswered questions, as well as the ability to engage in research that can be basic science, translational, clinical. You know, we, in my short time being a hepatologist, I have been able to witness, for example, the treatment of hepatitis C. When I first started off as a medical student and as a resident fellow, and then as a junior attending, you know, I directly observed the transition in treating patients with things like interferon to now with these very short course direct antiviral agents where we're able to cure the majority of patients with viral hepatitis C. There are not many subspecialties where you can kind of throughout one's life see that transition. The other main transition, I guess you can call it, that we are able to see is taking a patient who is sick with end-stage liver disease and really giving them a fresh start with a liver transplant is a remarkable thing that for me, at least, will never get old and allows me to help somebody at the most sick and vulnerable point of their life and then give them an opportunity to go out and live the rest of their life as a healthy person is really just a remarkable way to spend your career. For some people, the ability to do procedures attracts them to this field. Of course, you know, having gained endoscopic skills in GI fellowship, that's not something that you want to lose necessarily. And so the ability to continue to provide your patients with their endoscopic care as a hepatologist is very appealing. Likewise, doing other procedures like liver biopsies or paracentesis might attract some people. And then I, you know, I will say that one of the other areas that I think is just ripe is the ethical part of liver transplantation and really thinking about, you know, organ allocation with this very precious resource we have and the diseases that sometimes have led people to end stage liver disease, having a stigma associated with them, being able to kind of critically evaluate those issues and tackle them and have interesting ethical debates, whether it's amongst your team or just in the liver transplant community is quite intriguing to me. Lastly, I'll say that I think one of the major draws for me is interpersonal relationships. And I mean that with patients and within my own team. I very much enjoy having long-term relationships with patients, and that is certainly something that you get in a career in transplant hepatology. And I also enjoy having strong relationships with the people that I work with every day. I always say that liver transplantation or transplant hepatology is the ultimate team sport because it really does take a village to get a patient through a transplant. I absolutely rely on my fellow hepatologists and my surgical colleagues, our social workers, psychiatrists, financial coordinators, transplant waiting list coordinators, nurse practitioners, physician's assistants, and everybody who contributes to the team. I love being part of a big, diverse, multifaceted team that I think takes excellent care of patients. One of the other things that I think is worth highlighting about my career in academic hepatology is really the diversity that one can see in their career. I can spend my days delving into patient care, complex and intellectually stimulating cases, but there's also a lot of other avenues that one can take as a transplant hepatologist. Over the last few years, I've become much more involved in operations and innovation in transplantation. I think that taking on leadership roles within your center is something that's definitely a possibility when you enter a career in transplant hepatology. Creating new programs or ways for patients to flow through the system or disease-specific clinics or efforts is something that one can think about. And really honing in on kind of an operational focus is something that might appeal to many people. Then there are those people who are going to take the more research route, and those are people who are involved in clinical basic and translational research. And then there are some people who might have more of an educational interest. I certainly have taken this approach in my career, being involved at both the medical student and graduate medical education level. I enjoy combining a great deal of research into my everyday practice. And I think that the ability to kind of have that diversity in a single career, although I'm focused on transplant hepatology, being able to pivot to those different areas is really remarkable. And it's something that is, I think, somewhat unique to this field. This is just an example of a tweet that I had on my personal Twitter page where I was commenting on the perfect example of diversity in my job. I was presenting a graduate medical education project to the board of New York Presbyterian Hospital. And then in the afternoon had selection committee meeting where I was able to list the patient for transplant. And then following that, I was donning white coats for the medical students at their white coat ceremony. And that was a year ago from now. And I felt like that I wanted to celebrate with this tweet that I really am, through transplant hepatology, able to have this diversity in my career. So what does this really look like? And I would say that this changes on a week-to-week basis. If it's a week that one's on service, you can dedicate all your time to kind of the clinical mission. Then there are going to be weeks where I'm running my course in the medical school. So I'm most focused on that. But, you know, the ability to kind of reprioritize things through the week kind of allows you to focus on different things and have different pockets of interest. I think on a year-to-year basis, what this means, it allows you to kind of say, you know, I really want to hone in on these educational efforts that I'm involved with, or I really see myself more in operations and I want to run the transplant floor. I want to run a program within the program, like the live donor program. And, you know, getting to kind of learn more about the operational functioning and thinking about the quality of the programs that you're running is something that one can get interested in. And then over longer periods of time, you know, the focus might change, but, you know, the ability to kind of have this breadth of involvement in a program, in a clinical space and in a medical center is really remarkable. I really enjoy what it is that I do on a day-to-day basis. And I think one of the things that is worth mentioning is that the outset of this, I never would have thought that I was somebody who maybe had kind of such an operational or educational role. I thought that I would be somebody who took care of patients as the predominant thing. And although that is maintained as a very important and active part of my career, over time, that has changed. And there are other things that I enjoy that make my career and my fulfillment more complete. And I think that that would not have been possible had I not been involved in a career in transplant hepatology. Hello, everyone. My name is Nazar Mukhtar, and I'll be talking to you about hepatology careers and private practice in the time of COVID-19. Thank you to the course organizers, Dr. Zaparna-Goyal and Brian Kim, for inviting me to be a part of this excellent career development workshop. I have no relevant conflicts of interest to disclose. I currently serve as Director of Hepatology at the Kaiser Permanente San Francisco Medical Center and Associate Program Director for our recently launched Kaiser Permanente Northern California Gastroenterology Fellowship Program. As a trainee and now a young faculty member, I've always found it helpful to gain the perspective of others and to learn about the various career paths out there in medicine and within hepatology specifically. During this talk, I wanted to share with you a little bit about my own career path, describe what it's like to be a hepatologist in a private practice or a non-university setting, describe how COVID-19 has impacted our work, and provide some tips or guidelines for individuals exploring hepatology positions now or in the near future. I grew up between the wonderful Big Apple and Khartoum, Sudan, where I'm from originally. I got my bachelor's degree from the University of Maryland before spending a wonderful four years in the country music capital of the world, obtaining my medical degree from Vanderbilt, which I loved. I then moved out to beautiful San Francisco where I completed training in internal medicine and subsequently stayed on to complete a fellowship in GI and transplant hepatology. In fact, I was UCSF's first fellow to complete the combined GI and transplant hepatology fellowship, which was fantastic. I definitely want to thank one of our other workshop faculty, Dr. Oren Fix, for helping to launch that program. I then moved out to Seattle to join the Organ Transplant and Liver Center as a transplant hepatologist, and was on staff there for under four years before transitioning to my current role at Kaiser Permanente. Like many, I was drawn to the field of medicine and specifically hepatology in large part because of all the opportunities it afforded me to explore my interests that really extend beyond direct patient care. Throughout my journey, I've been inspired and motivated by mentors who wore many different hats and really excelled across a variety of roles. And I wanted to emulate this, and this ability or freedom to do so was very important to me as I explored training and job opportunities. While my greatest passion is patient care and being at the patient bedside, the work that I do in these other arenas really adds a great deal of color to my work and helps keep my day-to-day work exciting, dynamic, and challenging. So for those of you pursuing hepatology as a career, the vast majority of you will be obtaining your training or have completed your training at a university medical center. And one of the key things I want you to come away with from this session is that there are indeed general and transplant hepatology positions outside of the university setting that will offer you equal and sometimes even more opportunity to pursue some of these academic, scholarly, or administrative pursuits if that is important to you. Notably, however, promotion or career advancement in these settings is not necessarily tied to these academic pursuits. And there are certainly many colleagues who prefer to focus on patient care, which is perfectly fine and can align quite well with the priorities for many positions in private practice and provide a great deal of flexibility. So what exactly does a hepatologist do in private practice settings? As shown in this slide, we're primarily responsible for the evaluation of patients with acute and chronic liver diseases in both the outpatient and inpatient settings. We play a central role in pre-transplant and perioperative management of patients with end-stage liver disease, requiring liver transplantation. And at many centers, we take a lead role in post-transplant management of patients. Hepatologists also lead the management of patients with liver cancer, serving a pivotal role in multidisciplinary liver tumor boards. And the majority of hepatologists are trained in endoscopic evaluation, including EGD and colonoscopy, with some also having expertise in advanced procedures such as ERCP. Though the amount of general GI and endoscopy responsibilities can really vary widely across practices. In terms of academic or administrative pursuits, as I alluded to in my own journey, the opportunities to pursue your interests are truly abundant, and this just speaks to how much hepatologists can contribute towards efforts at the local, national, and international level to improve liver disease prevention and management. And you need only ask some of your mentors or colleagues in organizations like AASLD for ideas on how you can engage in these rewarding activities. Like many specialties, we've had to adapt a fair bit to meet the needs of our patients during these challenging times. And fortunately, from talking to colleagues across institutions, most GI and hepatology practices have adapted quite successfully with demand for services remaining high and job security remaining in good shape. Most practices did see or continue to see a disruption in services offered or patient willingness to proceed with some of our more preventive or healthcare maintenance items, such as liver cancer screening. And we'll certainly need to study the implications this will have on patient outcomes in the years to come. I'm certain the pandemic will also likely heighten the disparities in liver disease across racial and ethnic groups, given the disproportionate burden COVID-19 has had on our Latinx and black communities, which is another area we must focus our efforts on. There has been, continues to be a lot of work across GI and hepatology practices to create new clinical workflows, to ensure patients get timely and effective care, particularly for our patients with end-stage liver disease and liver cancer. And I'm sure these efforts will be ongoing. So I'll end my segment with a few words of advice for those of you pursuing hepatology positions currently or in the near future. You don't wanna be this person in this cartoon. You have to firstly realize that your unique skillset will allow you to provide value-added care and that you are or will be an asset to any organization. Along these lines, when negotiating a position, you should not be afraid to ask for what you think will help you to be successful. Because in the end, what I've learned is that if you don't ask for it, you probably won't get it. You should take the time to learn as much as possible about your future colleagues and the culture of the organization that you're joining as a whole. In the end, these are the people you'll interact with day in and day out. And because the care of patients with liver disease really does take a village, you wanna work with people you admire and trust and who are actually happy or who at least find fulfillment in helping you care for your mutual patients. Taking factors, consider factors in your life outside of work. Think about location, opportunities for you to pursue your hobbies or interests, be it hiking or frequenting restaurants as we did once upon a time, and proximity to friends and family. I cannot overstate the importance of this. Keep an open mind and explore opportunities in various settings beyond your comfort zone because you never know, you may actually be pleasantly surprised by what is out there. Talk to your mentors, family and friends, share your excitement, your concerns. These discussions will help you sort out your priorities and determine if the job you're considering aligns well with them. And lastly, trust yourself. Go with your gut and trust your instincts. They will usually steer you in the right direction. So I'll stop there and I'll leave you with these takeaways. Hepatologists add value to organizations. You have to appreciate and recognize that. You should explore your options and consider hepatology positions in private practice settings as these will come in all shapes and forms. We are well poised to provide excellent care during the COVID-19 pandemic and beyond. And as you develop your rewarding career in hepatology, I encourage you to continually seek opportunities that will stimulate you and add to your personal and professional growth. Thank you so much for listening. I'm very excited to be a part of the hepatology community and I encourage you to reach out if you need any advice during your journey. I've relied on the advice of tremendous colleagues and friends over the years and I encourage you to do the same. We're happy to help. Thank you so much.

hepatology careers

patient care

research

procedural interests

clinical pathology

career advancement

private practice settings

transplant management

liver cancer care

COVID-19 impact