Hi. I'd like to thank Drs. Kim and Dr. Poorman for the invitation to speak at this year's Career Development Workshop. I'm Warren Fix. I'm the Medical Director of Liver Transplantation at the University of North Carolina at Chapel Hill, and I have no relevant disclosures for this talk. So, there are currently two pathways for hepatology certification in the United States. The first is the traditional pathway, or 3 plus 1, which involves three years of GI fellowship, followed by one year of transplant hepatology fellowship. The second pathway is a relatively new pathway called the dual certification pathway, formerly known as the pilot, which embeds transplant hepatology training within the three years of GI training. And successful graduates are eligible then to take the ABIM GI certification exam, followed by the transplant hepatology certification exam, and then they can be certified in two specialties after three years of training instead of four. The dual certification pathway is an ABIM-approved training pathway and has specific ACGME program requirements attached to it. Because it's pretty heavily clinically focused, there's 18 months of clinical GI and 12 months of clinical hepatology. It's really ideal for those who are interested in a clinically focused career. And there are many hepatology career paths. You're going to hear about some of them later in this workshop. Really for any of these career paths, you're ideally suited to get specialized training. This could be clinically focused in some cases, but in others, you're going to need additional training to prepare for your career. The ACGME GI program requirements state that the educational program has to be 36 months in length and that a minimum of 18 of those months must be devoted to clinical experience. Five of those 18 months need to be in hepatology. So we learn a lot from these two requirements. One, that hepatology is part of gastroenterology training. A gastroenterologist manages general hepatology. And this is just part of the competency of GI. The other thing we learn is that there's a lot of time. There's 18 months during which you can do a lot of additional work that's not required by ACGME. What you do at that time depends on your specific program's requirements, but should also be defined by achieving competency in GI and in achieving the goals of your career. When considering specialized hepatology training beyond a standard GI fellowship, a fundamental question to ask is, what is a hepatologist? Or is a hepatologist different from a gastroenterologist who sees mostly liver patients? Is a hepatologist different from a transplant hepatologist? Well, we were able to make a case for creating a new specialty back in 2006 that now has its own ABIM board, an exam, ACGME program requirements, all of this because we had workforce data that demonstrated that hepatologists possessed skills and expertise that were distinct from general gastroenterologists. Gastroenterologists refer their patients to hepatologists often because of their complexity. Now, some will argue that a hepatologist and a transplant hepatologist are different skill sets and job descriptions, but I disagree. So why is our specialty called transplant hepatology? Well, at the time, we needed a concrete way to distinguish the skills and competencies of a specially trained hepatologist from a gastroenterologist. And transplant was just one relatively simple way to make that distinction. It was important at that time to make sure that we were not taking all management of liver disease from gastroenterologists. And still, there isn't a big appetite to decouple hepatology from gastroenterology. We still need to go through GI training and certification in order to become trained and certified in transplant hepatology. Now, there is such training where hepatology is decoupled from gastroenterology, but it doesn't lead to certification and it's not accredited by the ACGME. I personally think there are very good and practical reasons why hepatology should remain a subspecialty of GI. But the truth is that transplant hepatology is much more than just transplant. And I think the name has deterred many who would otherwise seek additional training in hepatology. They might reasonably ask, why do I need another year of training? Or they might not be aware of the benefits of hepatology certification. They may not want to work in an academic institution or in a transplant program and mistakenly assume that the additional training is specifically for those purposes, for academic or transplant careers. But hepatology is much more than just transplant. Hepatologists manage the full spectrum of liver disease, including complex problems like decompensated cirrhosis, of which transplantation is a part. I don't think a general hepatologist can expertly manage a patient with decompensated cirrhosis or liver cancer, for example, without understanding the process that patient may go through to be evaluated and eventually undergo liver transplantation. And from my personal experience with several jobs in transplant hepatology, multiple institutions, including academic and non-academic, the vast majority of my work has been in general or non-transplant hepatology using skills that I learned in my transplant hepatology fellowship and not in my GI fellowship. By obtaining the skills to manage the full spectrum of liver disease, you'll open up the possibilities in your career. You won't be restricted to practicing in an academic institution or a transplant program, but you could if that's your goal. And you would not be wasting your time while learning to manage complex liver problems, including transplantation. So I think it's time that we change the specialty's name to avoid the confusion it's caused about what hepatologists do, what the training involves, and why the additional training is important for anyone who's pursuing their career as a hepatologist. I suggest a name like advanced liver disease or advanced hepatology, and there is already momentum for such a change. I don't think this kind of a name change means that training has to fundamentally change, rather the name will more accurately reflect the current training and the current practice of hepatology as distinct from gastroenterology. It's important to understand the advantages and disadvantages of certification in transplant hepatology. I think it demonstrates your expertise to employers, colleagues, patients, the public. It may get you a higher salary. It may open the door for leadership positions, and it may give you a competitive advantage in the job market. The disadvantages are that it does require additional training, which may mean an additional year of training. It does require an additional certification exam, and it may require additional maintenance of certification exams, although the MOC space is evolving. We recently completed a workforce study that concluded that there is a large need for hepatologists and that that need will only grow as the liver disease population grows and more hepatologists retire from the workforce. Fatty liver disease, non-alcoholic, excuse me, alcohol-associated liver disease, liver cancer, these are just a few of the diseases we manage that are only rapidly growing. But this deficit is not uniform throughout the country. So even though you may have job security by becoming a hepatologist because of this evolving deficit, there's generally metropolitan areas and large academic centers where they are already saturated, and these are generally places where people want to work and live. So even though you have pretty good job security by becoming a hepatologist, the certification part may be the advantage you need to secure a job where you want to live and work. Are four years of training necessary? You just heard that there is a three-year option for certification, so what is the advantage of a fourth year? Well, you know, I think we've shown with the dual certification pathway that it is possible to achieve competence in two specialties in three years, in less time than the four years that used to be required. But I think time should not be the main factor in determining competence, but it's definitely still important. Experience still matters. Some people may want more time or need more time to develop competence in gastroenterology. Some may want that additional year of clinical experience before they become independently practicing providers. Some may want time to focus on other interests, say research or another degree. Now the disadvantages are that time spent in GI clinical rotations or GI conferences could be time away from your career interests, and that fourth year is a potential deterrent to additional training and certification in hepatology, and really one of the main reasons why we developed that dual certification pathway. The application process for the fourth year fellowship has traditionally started about 18 months before the start of hepatology training. This is hopefully changing. Probably the first place to look for training programs is the ACGME website, where there are currently 62 accredited programs in the U.S., and that number keeps growing each year. But it's important that you look at individual program websites because there isn't a standard application or interview process and you want to know what each program is going to require. Definitely use your program director and mentors to help you select programs and connect you to faculty there. All programs require a CV, letters of recommendation, and a personal statement, and many will require procedure logs and transcripts. As I mentioned, the application process might be changing, and I want to highlight the work of Danielle Brandman at UCSF and others who are trying to hashtag positive chaos. This 18-plus monthly time for applications has been getting earlier and earlier every year, and many applicants don't get a chance to interview and consider all the programs they're interested in before they're forced to make a decision about offers. This process has long benefited programs over applicants, and I'm glad to see that this may be changing. I don't think hepatology is going to have a match. We're really too small of a specialty, but here is a list of 38 programs who have pledged to defer hepatology fellowship interviews for the academic year 23-24 to next spring instead of having just done it this year. I think it's a great start. I hope the remaining programs follow suit, but unfortunately, it means that at least for now, there are two timelines. There are some programs who are interviewing now or have just interviewed for academic year 23-24 and other programs that won't start until next year. So you still need to plan well in advance to get your applications in and to make sure that you get access to all the programs you're interested in, at least until this whole process plays out. Now for the dual certification pathway, the application process is the same as GI because the training is part of GI fellowship, and that's part of a match, so it's less chaotic. But make your interest in hepatology known early in the application process or definitely in the interviews, although every program that's affiliated with a transplant hepatology fellowship could do the dual pathway. Not every program is doing it or not every program can do it every year, and many programs can't guarantee it upon matching, so something you definitely want to discuss in the interview process. There are many factors you can use to help you choose a program. Geography is one helpful way if you've got a constraint, and that will help narrow down some of the programs you're looking at. Mentorship and a research interest can help if you have a particular niche. Think about where you want to practice. Many people end up practicing in the program or the city where they trained. I think program size is very important. This graph shows that there's a huge variation in transplant volume throughout the country. Even if you're not interested or planning to practice in a transplant program or a large transplant program, I think the more experience you get during training, the better for when you get out into practice, so consider that as a factor. And also think about the availability of the dual certification pathway, as I mentioned. So my key takeaways. There are two pathways to transplant hepatology certification, the traditional fourth-year or 3 plus 1 pathway and the dual GI transplant hepatology certification, previously known as the pilot. Those with a clinical hepatology career interest may prefer the dual certification pathway. Those with an academic or research-focused career interest should use the third year of GI fellowship to develop the necessary skills for their career. Hepatology requires specialized training, and it may require an additional year of training beyond GI fellowship. Specialized hepatology training is useful whether or not you are interested in a transplant-focused or academic career. I think the name transplant hepatology should be changed to better reflect what hepatologists do. And begin your program search and application process early, but fortunately this process seems to be changing. I thank you very much for your attention. So my name is Brian Lee, and I'm an assistant professor of medicine at Keck School of Medicine of USC, and today we'll be talking about how to optimize your fellowship time. I'm a transplant hepatologist, and I'm a physician scientist, so many of the personal examples I'll be using during this presentation are research-related, but the principles can be applied to any career path during fellowship. I have no financial disclosures. The objectives of this talk are to recognize signs of inadequate time management, to outline steps to optimize your time in fellowship, and to highlight key areas that allow for post-fellowship steps. I've tried to make this talk as expert and evidence-based as possible, consulting literature rather than my own opinion, so as a disclaimer, I don't necessarily practice everything that I'll be discussing, and I think that's okay. You should approach this talk as recommendations rather than things that you have to do. So what is time management? Time management is the process of arranging your tasks to ensure that you have enough time to complete every task that is important to achieve your goals. It's important to recognize signs of poor time management. During fellowship, examples in the clinical world would be inadequate preparedness for rounds or clinic, or notes that are not completed within a timely manner. In the research world, this might manifest as incomplete projects or deadline extensions. Effective time management is essential to become a successful and competent physician, and is associated with not only improved work satisfaction, but also work-home life integration and all subsubjective personal well-being. It's important to be frank. Counting school and residency, you've completed about 21 years of formal training at this point. You've made it to the near end of the marathon, but the reality is you're not done yet, and fellowship is still long, and it's stressful, and many of you are moving to a new city and will need a new routine. It's a lot, and it's normal to feel tired this late into the marathon, and at times you might feel like it's a lot to get to the end. You've made it this far, and this is an important step to launch your career, so it's important to do everything you can to optimize your time, and make fellowship as smooth as possible. We'll talk about strategies to do this, framed as the three P's of time management, planning, prioritizing, and performing. We'll start with the first P, planning. It's important to plan for the post-fellowship early on, and to really think about what you want to do after fellowship. We're lucky in that there are many possibilities, research, clinician educator, private practice, industry. These are all possibilities. A lot of opportunities that can facilitate your post-fellowship goals require decision making in the first year of GI fellowship. For example, the combined GI training pathway for transplant hepatology, T32 grants for pursuing a research career, or applying for an ASLD transplant fellowship award are opportunities that require a decision by the end of the first year. Plan with help. There are many people who have been and are in your shoes. Take advantage and lean on that shared experience. At the beginning, shadow a senior fellow who's efficient, and ask to get their smart phrases and note templates. With your co-fellows, share responsibilities and help each other with coverage. The longer your bond with your co-fellows becomes, the easier and more enjoyable your life will be in fellowship. So spend time together outside of work, and build those relationships. Next, invest the time to find the right mentor. Having effective guidance is critical to keep your tasks in check. For me during fellowship, Neil Mehta and Nora Thoreau were instrumental to my development, and still are. I chose them very carefully. They had a track record of successful mentorship, with past mentees who have been successful on the track that I wanted to follow, the physician-scientist route. Next, you want to find mentors who will focus on your development and interests. My research and clinical passion since residency has been early liver transplantation for alcohol-associated hepatitis. But when I was transitioning to fellowship, many people discouraged me from further pursuing this topic. Much of the reason that I connected with Neil and Nora is that they supported and encouraged me to follow this passion. You want a mentor who is interested in helping you with your projects and cultivating your long-term goals. Meet regularly. Your mentor may be a busy person, and you will be too, but find a way to get on their schedule regularly. For example, I meet with Nora at least once a week. The time is invaluable, so make best use of the time, and prepare an agenda of what you want to discuss beforehand. And given how much time you will be spending with your mentors, choose mentors that you feel like you can spend a lot of time with. If it's somebody where your personalities don't click, it's not going to be a healthy and productive relationship. Finally, think about a mentorship team rather than just one mentor. For me, having one junior faculty, Neil, who might have more time and accessibility for day-to-day questions, combined with a senior faculty who may be busier but makes higher-level decisions is an efficient way to maximize the benefits of mentorship during fellowship. Next, think about finding and cultivating a niche. Making yourself stand out with unique expertise can go a long way. To do that, you should consider what you see yourself doing in the future. What makes you excited? Do you find the work fulfilling? Are you skilled and talented in the area? Can you see yourself doing this for 10 to 20-plus years? Is there a need for the work? Working on something important where you can make useful contributions can be fulfilling and motivating. So once you have plans for how you envision the future and are equipped with the right mentorship team, the next broad category is to prioritize. So this is a key slide which provides an overview of the Eisenhower time matrix. The Eisenhower time matrix is a popular way to prioritize tasks. The matrix divides tasks into four quadrants. The matrix tells you to think about tasks by important versus not important and urgent versus not urgent. In quadrant one, these are tasks that are urgent and important. Quadrant one tasks you should address immediately. Examples of quadrant one activities in fellowship will include clinical care and emergencies. In quadrant two, these are tasks that are not urgent but are important. Quadrant two tasks focus on long-term development and strategy. I've highlighted quadrant two in red because these are activities that you will likely need to find ways to plan but are important to prioritize and to fulfill your goals. Quadrant two activities include research projects, but also wellness, exercise, and recreation. In Quadrant 3, these are tasks that are seemingly urgent, but not important. These are tasks that you should minimize, eliminate, or delegate. Examples of Quadrant 3 activities can include research projects that have no relevance to your niche and clinical scut work. In Quadrant 4, these are tasks that are neither urgent nor important. Examples of Quadrant 4 activities, which we're all guilty of, include trivial busywork and endless TV. You should eliminate Quadrant 4 tasks as much as possible. So you now have a framework to prioritize tasks. Effective prioritizing should reshape how you plan to address the tasks. I recommend that you tackle your schedule week by week, and to put all your tasks of the week in the four-quadrant matrix to assess yourself. Fellowship will bring lots of Quadrant 1 activities, particularly in the form of clinical care, but make sure that each week does include some Quadrant 2 activities, whether they're wellness, seeing friends or family, or research activities. When time is more limited in the week, which will often be in inpatient service weeks, find activities that combine Quadrant 2 priorities. For example, exercise outdoors and spending time with friends is important to me, so going on a hike with friends combines wellness, exercise, and social priorities all at once. Some goals will only be able to be achieved on certain days, like activities with your children on Saturdays. Planning your week allows you to designate a cumulative block of time, like Sunday afternoon, for relaxation and inspiration that will be uplifting. It also allows for flexibility for tasks to get accomplished and sets you up for less disappointment. It also helps you look beyond too many Quadrant 1 activities, like clinical crises or Quadrant 3 busywork, that can dominate your day-to-day. Rather, planning in longer-term units of time helps guarantee that you schedule Quadrant 2 activities. Finally, be adaptable and don't feel guilty if the schedule changes. There will always be unexpected things happening in fellowship, so just acknowledge that and focus on how you will address these unexpected changes in a healthy manner. So how do you identify the right project to say yes to? First, recognize that time is limited during fellowship. Only take on projects that you can realistically complete during fellowship and on time. It's impossible to know for sure where you'll be after fellowship. Next, tailor projects to your niche. For example, taking on a research project that isn't what you want to specialize in won't help you in the future and won't be fulfilling either. Align projects with your long-term values and goals. If the project doesn't meet these criteria, it's okay to say no. When somebody approaches me for a long-term project, I say that I need to discuss with my mentor first. It gives you time to think about whether the project aligns with your long-term goals without being reactionary, provides an opportunity to discuss with somebody who is more experienced and cares about your long-term development, and also gives you an easy way to say no when you can say that to the person that you've been thoughtful and have been advised against it after discussion with your mentor. So we've covered planning and prioritizing. We'll now move on to the final P of time management, which is performing. To optimize your performance, create a routine as much as possible, especially for crunch periods. For example, inpatient months are likely to be the busiest periods, so you should plan accordingly. During these crunch periods where you anticipate a lot of work-related stress, minimize sources of potential non-work related stress. For example, prep meals in advance, do laundry and dry cleaning beforehand. A cleaning service for your home is a luxury, sure, but if it helps you create a more comfortable environment when you get home from work and helps you recharge more efficiently, it might be worth the cost. Other routines that are easy to set during fellowship include how you pre-round and running the list with your team in the early afternoon. Most clinical care should feel automatic, so you have time and energy to appropriately address special and perhaps more energy-consuming circumstances that come your way, like diagnostic mysteries, acute emergencies, and goals of care discussions. Next, take full advantages of time off. When you know that you have time off in advance, make it feel special and plan quadrant two activities that help you recharge. I included a picture of my favorite beach in Malibu, which is one of my favorite places to go when I have time off. The next key to performing well is solicit feedback. Objective views from peers and more experienced faculty can help improve your performance and save time during fellowship. I recommend that you ask clinical attendings for feedback in clinic and after inpatient weeks. For research, you should present at works in progress meetings. Accepting feedback is a skill in itself. Prepare yourself before you ask for feedback. Mentally tell yourself not to take things personally and don't be defensive. Ask questions if the feedback is vague or you don't understand. Ask for specific examples and how they feel that you can improve. The more you ask for feedback, the less awkward it will become. Finally, don't get caught in activity traps. It's possible to be very, very busy without being effective, to work harder and harder and climbing the ladder only to find out that it's leaning against the wrong wall. Always assess what you're performing before you take on tasks and make sure that they align with your long-term goals. If they don't align, find ways to say no or to delegate. How do people delegate effectively? Many people don't delegate because they feel they think it would be faster or that they can do a better job themselves. The reality is you can't do it all yourself. This is okay and it's better for you and everybody around you to let go. Stephen Covey strategized delegation styles as gopher versus stewardship delegation. Gopher delegation is micromanaging where you tell somebody to go for this, to go for that at every step of the way. Stewardship delegation focuses on the results, not the methods. You let the person you're delegating to become the steward of the task. You create a mutual understanding of what you expect the results to be. What, not how. For example, running the list of tasks for the day after rounds of stewardship delegation. Be a delegator, not a dictator. You make it clear that you want to help and are available to help should they run into problems. Check in and be available to make sure that things are on track and the tasks are veering off course, don't become crises. For example, I run the list again in the early afternoon so we have time to troubleshoot problems with tasks that aren't on track before it becomes too late into the day. With all the interest in becoming more efficient and optimizing time management, there are now many apps to help. These are some of the most popular ones. Things 3 helps make to-do lists and tracks project progress. Notion and Asana are task and project managers. Finally, here are some general tips. Identify your most productive time of day and plan to complete your most important work during that time. So for me, I'm most productive in the early morning, so I try to do all my writing creative tasks during that time. I try to schedule all my meetings that don't require as much brain power for the afternoon rather than the morning. Next, avoid multitasking during important tasks like writing a manuscript. Finally, maintain balance. Success in one area, i.e. professional, cannot compensate for failure in other areas of life like personal relationships or health and will impede long-term success and fulfillment. So here are some take-home points. Fellowship is busy and stressful. Time management is important to optimize well-being and future success. Planning, prioritizing, and performing are key to time management. Deciding what you want to do early in fellowship allows effective alignment of three Ps with your long-term goals. Finding the right mentors is critical at this stage in your career. So best of luck and thank you. 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 and early faculty. And we wrote a couple years ago an article that essentially celebrated what we learned about rising the ladder together. And 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 have 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 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 time frame 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 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, 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 other 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-mentor, 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 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. 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. Mentors 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 one, understand the kind of factors that need to be described for future multivariable analysis in tables two and three. So if you find things like the etiology of liver disease, MELD score, the presence of acute or chronic liver failure are important, then 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 days 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. And it's 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. Hello everyone, my name is Lauren Nephew and I am a transplant pathologist at the Indiana University School of Medicine. And I am very excited to be with you all to share my career perspectives about being an academic hepatologist. When I was a medical student, a fellow and a resident, I very much wanted to understand what life would be like once I arrived to attending Hood and academic medicine. And so I'm delighted to share with you some insights about my experience thus far. I have nothing to disclose. So an overview of what we will discuss today includes this idea of being a quadruple threat. I say quadruple threat because often in academic medicine, you hear about being a triple threat, which includes patient care, research, and teaching, but that leaves out service, which I'll define for you. And that's a very important part of work in academic medicine. So we'll talk about managing being a quadruple threat. We'll also briefly discuss what it means to be on a tenure track in academic medicine, given this is a very important component of most people's academic life. And then we'll talk a bit about work in life. I won't use the word balance because I'm not sure to ever imbalance, but we'll talk about the importance of managing life while also doing all this very important work in academia. So I'll start off by sharing with you my weekly schedule. So I am 70% research and 30% clinical. And so this is a 70-30 weekly schedule. And if you're not familiar with the kind of percentages that are often used to describe academic research versus clinical work, each half a day in a week is about 10%. And so there are five days or 100%. Five days make up 100%. And so if you look at my schedule on any given Monday morning, I do clinical work that represents 10% of my week. And my Monday clinical work is my pre-transplant clinic. I evaluate patients who are in need of liver transplantation in that clinic. Then in the afternoon, I put on my research hat and I devote most of my time to very kind of intense research meetings. One, my large team meeting with folks in our division who do hepatology research. And then the second part of my afternoon with my specific research pod in cirrhosis. And so my afternoon, 10% is research on Mondays. Tuesday mornings, I usually get up and I have a number of messages in my inbox and labs. And so that's administrative slash clinical time where I call patients, I review labs, and I close some of my notes from Monday. I often also prepare for our liver transplant committee meeting, which is on Tuesday afternoons. And I consider this clinical work because I'm discussing patients, discussing patient care and eligibility for transplant. That meeting usually finishes around 3.30. And then I go back to finishing some of my administrative tasks, following up on clinical work from the transplant committee meeting, as well as my clinic from Monday morning. Wednesday, I spend both mornings and afternoons exclusively on research. And if you are in academics, you'll find it is very, very important that you find time that's dedicated and blocked out to your research. And so I never schedule meetings on Wednesdays. I don't schedule classes on Wednesdays to teach. I don't do any mentoring on Wednesdays. I exclusively leave that to writing, reviewing data and research-related tasks. And everyone knows that, that that day is gonna be exclusively devoted to that work. Similarly, Thursday is fully clinical. So on morning, I do endoscopy. So some of us hepatologists still do scope. And so in the mornings I do colonoscopies and upper endoscopy in our endoscopy center. And then in the afternoon, I see general hepatology patients. So patients who are not yet on the transplant track, but who still need hepatology care. Friday is I consider a mixed day. I usually do some research in the morning because I find that my best writing is done in the morning. And that'll be important to figure out if you're academic, whether you're on a research or clinical track, when you do your best kind of scholarly work. And then in the afternoon, I do a lot of my meetings. And so Fridays, I meet with mentees. I also often schedule service meetings, service to the university, service to the ASLD, so different committee work. And then I may also schedule some research meetings with collaborators on Friday afternoons. Friday, there's often this tendency to kind of wanna get out and start your weekend. And so to protect that time, make sure I'm using it well, I often schedule meetings. And so I don't have a way to get out early on Fridays. So kind of speaking more specifically to the different hats that people often wear in academics, using myself as an example. So the patient care hat for me involves seeing both transplant patients and general hepatology patients. And that's gonna vary depending on where you practice, whether you see both or whether you dedicate your time to one or the other. In addition to my clinical work as an outpatient, I also do six to eight weeks on our inpatient transplant service. We have a dedicated service to patients who are pre and post transplant. And occasionally I also round on our consult service. This is exciting work because you get to do clinical work as well as to teach the residents and how staff are on service. And our practice, which is fairly large, we take call twice a month overnight at home, and that involves triaging overnight consults from outside hospitals, as well as helping our house staff to admit patients overnight and to answer their questions. As I discussed with you, I also do endoscopy on Thursday mornings and take a week of bleeder call where I cover emergent cases overnight at our three hospitals. And finally, I attend transplant selection meetings, which is an important part of clinical care and transplant hepatology. Research is the biggest hat that I wear. So in academics, you'll find that some people are 50-50 research and clinical and then you'll find some folks like myself who do mostly research and then others who do mostly clinical work. I do mostly research. I have trained to do that. I did a fifth year in medical school that was devoted to clinical research. I got a master's in ethics while I was a medical student and then a master's in epidemiology while I was in GI fellowship. And so I really kind of set myself up to have this academic 70-30 research career. And if you haven't, that doesn't mean it's too late, but often people fall into these phenotypes fairly early. And the focus of my work is understanding social determinants of health and race and gender and the role they play in accessing liver transplant and stage liver disease care. And so for me, because that was the work I wanted to do, I really needed to be in academics because that's where most transplants actually happen. One of the benefits of being in academics is that the mentorship can really be multidisciplinary. So when you do transplant and disparities work, you really need to be able to access biostatisticians, people from the public health school, people from the nursing school who are really good at implementation science. And so being in an academic center allows me to do that. It also allows me to have a number of peer mentors in our division and even outside of our division and a number of collaborators within the School of Public Health and Bioinformatics and really allows for kind of rich research. In terms of how I divide my research time, I spend the bulk of my time writing and executing projects. So cleaning data, analyzing data, and then writing papers. Next, I spend a fair amount of my time also writing grants. Early in your career, it's important to secure funding for your work. And so I try to devote 25% or so of my time to writing and renewing grants. And then finally, I spend some time fleshing out new ideas, reading the literature, going to meetings, trying to decide where I want to go next. And then there's research service, I call it, where you review papers for journals and papers for your collaborators and peers, which is really a good way to be of service, but also a good way to kind of get ideas about where you might go next with your work. And so being in academics really allows you to be in this rich environment. If you want to do research, this multidisciplinary with a number of collaborators, a number of peers, and to really kind of work your time to really advance your research. In addition to the clinical work and the research work, I also do teaching and mentoring. And if you're going to be at an academic center, the expectation is that you're going to be involved in teaching residents and house staff as well as medical students. And so you'll give formal talks while on rounds and while you're on the inpatient service. And that counts towards your teaching. It's an important opportunity for medical students and house staff to learn on the go. Also, you may participate actually in a medical school. I help with a course on ethics of liver transplantation, and that's really a lot of fun for me. Also with our fellows, I help with journal clubs and I give talks on disparities in liver transplantation. And then you'll do mentorship. Many of us were mentored along the way and you want to give back. And so I mentored to undergraduate pre-med students, medical students, residents, and fellows. And that's really rewarding. And one of the benefits of being in academic medicine is really being able to give back to your mentees and really learn from your mentees as well. Finally, I think that one thing that's often not discussed is service. And so if you're in academic medicine, there's a lot of service work in giving back to your community of patients, the community where you live, and your community of physicians. So locally, for example, I'm a part of the All In for Health Advisory Board, which seeks to improve the health of Hoosiers in Indiana. I'm a part of the Autoimmune Hepatitis Advisory Board that helps to improve the lives of patients with autoimmune hepatitis. I am on the electives committee for the School of Medicine with the hopes of really helping our medical students really gain access to the electives that are really gonna advance their learning. I'm also a member of the IU Simon Cancer Center. So you can really be involved with patients, with medical students, really serving them and bringing your skillsets to their service. And nationally, in academics, and even outside of academics, service is important to be involved and to give back to your community like ASLD. I'm also a part of our inter-society group on diversity. So all of this work that you do, patient care, research, service, teaching, is all important in academic medicine. However, if you're on a tenure track, you may have one of those domains that's the most important. And for me, research is the most important because I am on the tenure research track. So tenure means that you get employment protection and you can hold this position in medicine once you obtain tenure, unless there's some gross negligence. The requirements to obtain tenure are gonna vary from institution to institution. But in general, the goal is that you have a coherent research program with publications and some in high-impact journals, that you have sustained grant funding, indicating that national groups think that your research is important, and that you have a national reputation, that your peers locally and nationally believe that your research is important to advance in the field of hepatology. Usually, institutions give investigators nine to 10 years maximum to achieve tenure, and a committee will review your dossier to decide if you've met these goals. And you will go up for review at IU, for example, at three or five years to just give you some feedback along the way. Research is not the only tenure track. There are people who are research, or excuse me, are a tenure, and they're tracked as service or clinical work, and there are people who are on the teaching track. But it's important that you have a national reputation, and you have some scholarly product for whatever area of tenure that you seek. And so this is an important part of academic medicine. Sometimes it makes people nervous, but I think that if you are consistently working towards these goals, and you know them up front, that there are mechanisms in place to help you achieve tenure so that you can have an employment protection, and go on in your research or clinical career. So finally, and importantly, I'll talk about work and life. I won't say balance, but how do you manage the two? I think it's important that you maintain your family and your friend connections. And just a couple of things to highlight. Children is something that often comes up in this discussion. When do you have children? And I've heard the myth that there's no good time to just have children. I would say I'm not quite sure if that's actually true. I think that having children in the first year of GI fellowship and first year faculty can be challenging, not impossible. But if you are scheduling having children, you may not wanna do it at those critical junctures. I'll also mention it's important to actively cultivate good friendships. That it's really easy to lose those friends from medical school residency and fellowship. You have to make an active effort to keep those people in your life. And it's important to your sanity. Because it takes a village of family and friends to manage your work and your life. There're gonna be times early in career where your family seems to be teetering towards the most heavy workload. And there'll be times where your work is the most heaviest later, perhaps in your career when your children are older. And it's important to have family and friends to help you get through that whole cycle. Self-care is also important. I block time in my calendar, specifically for facials and things that are important to me for my self-care. And my administrative assistant is aware that these are times that I'm not going to schedule meetings. And so I think that it's important if you don't block it in your calendar, but you make your time for yourself to work out or do whatever is your form of self-care. And my final piece of advice would be in academics that time is really a non-renewable resource. You cannot get it back. And you're trying to juggle so many hats. It's important that you value your time. And for example, let's say you make $200,000 a year and there are 263 working days in a year. Then that means that there's $763 you make per day or $95 an hour. Now we're not taking out taxes or anything like that. This is just an estimate for you to understand that your time is at least worth $95 to $100 an hour. And so if it costs less than that to do it, and it may be something that you want to consider sending out for someone else to do so that you can really do those things that are critical, like cultivating your good friendships and being with your family and not doing some of the things that other people may be able to do for you that you may be able to pay for service. So overall, I think work and life can both be done while you're in academics, but it takes a village. You have to value your time and really work towards some self-care. I'd like to thank you all for this opportunity to share with you my perspectives about being an academic hepatologist. And certainly reach out to me with any questions. If you're interested in health equity and other topics like this, follow me on Twitter. Good afternoon. I'm Mitchell Shiffman, Director of Liver Institute of Virginia. And I'd like to thank Drs. Kim and Pormand and ASSLD leadership for asking me to participate in this symposium. I'm going to talk about career perspectives from a community-based hepatologist. I have no conflicts pertaining to the content of this lecture. I have several industry relationships pertaining to other presentations I'm participating in during this meeting. So where do I get my perspective as a community-based hepatologist? Well, my career has spanned two halves. My first half of my career, I was in an academic medical center. This started in 1989 when I first joined the faculty of a major university medical center. And shortly thereafter, the head of hepatology left and I was thrust into the role to become the acting and then chief of the hepatology section and medical director of a new and slowly growing liver transplant program. I did the typical academic career. I started as an assistant professor and worked my way up to a full professor over the 20 years in my academic career. I was a consultant and speaker to industry. I received grants from NIH and pharma to conduct clinical research. I ended up publishing over 300 papers. But over time, I took on more administrative roles and less patient care. And the patient care I did take on was more and more fixated on end-stage liver disease and trying to keep patients alive for their liver transplant. I left the university practice in 2010 and have been there for the last 11 years. This is a hepatology-only clinical practice. It's grown significantly in these 11 years. We now have two offices, five nurse practitioners, and two physicians. And we provide clinical care every day. We see a wide scope of liver problems. In fact, the scope of liver problems we see in the community is much wider than what I did when I was at university practice. We do provide pre- and post-transplant care to our patients. We do take care of many patients with liver cancer. We also conduct clinical research. And since leaving academic practice, I've published an additional 72 papers from the clinical research studies I participated in. I also get my perspective from being in two eras of hepatology. For the first 20 years, I was in the golden era of hepatology, where all of the treatments we now take for granted were developed. When I first started in 1989, interferon was first utilized to treat non-A, non-B hepatitis. There was no hepatitis C at that time. We participated in studies which developed ERSO as the approved treatment for primary biliary cholangitis. The first antiviral agents for hepatitis B were developed. We finally identified and developed a test for hepatitis C, and then interferon evolved to PEG interferons, which became the main standard of therapy, along with ribavirin. Liver transplant programs started to expand. However, liver cancer treatments were still very limited, and only a fraction of patients with cancer could undergo liver transplantation or could undergo surgical resection. And finally, NAFLD was very uncommon. Now, hepatology is a well-established career. Hepatitis C is cured with antiviral agents. Hepatitis B is suppressed with antiviral agents. Liver transplant and living donor liver transplantation are common. Liver cancer has several different chemotherapies for treatment. And NAFLD has now become the most common liver disease, and probably the most frustrating of all the liver diseases we treat to deal with. After I was asked to give this talk, I kind of thought back about these two halves of my career. And when you think about where do patients get their care, the vast majority of patients obtain medical care in the communities where they reside or in the neighborhoods they reside if they're in a large metropolitan area. They usually don't go across town because specialists are generally plentiful in all of these neighborhoods. Hepatology is different. Hepatology has only recently emerged out of the silo of academic medicine, and there's still very few hepatologists practicing in the community. However, almost all liver diseases are now readily treatable or curable, and asymptomatic patients with non-sorotic liver disease no longer want to travel long distances to receive care for an asymptomatic, although chronic, disease. In addition, it's extremely difficult for patients with end-stage liver disease to travel long distances to large tertiary care medical centers, especially for pre-transplant care and also for the immediate post-transplant care. This is one thing I never really realized when I was medical director of a transplant, and patients were easily traveling two and three hours to see us, and it really took about three or four days to recover from that trip after that one clinic visit. And finally, there are now thousands of liver transplant recipients that are no longer followed by their transplant center because they're decades out and present to community physicians for care and need some expertise, which you can provide. Now, in the community, you can practice in various settings. You can go into solo practice. The problem with this is you're part physician, part small business owner, and given the increased regulatory burden of medicine and the increased costs of these regulations, solo practice really has questionable future viability. You can join a large gastroenterology practice and take care of all the liver disease for that group. I know several hepatologists that do this. However, it does require that you participate in colon cancer screening, do gastroenterology call, and all of these activities limit the growth of your liver practice. Finally, you can join a health system or a community-based hospital. This is really the future of medical care, as many of these health systems or hospitals are incorporating practices in their community as employees. Hepatology is a very lucrative field for a hospital. There's a lot of imaging, as you well know. There's a lot of testing, and this creates significant downstream revenue for the health system. Many years ago, there was a study that showed that for every dollar a physician charges, the health system will generate $7 of testing. Finally, by being an employee, you have the financial protection of not having to meet payroll as a solo practitioner or confronting your gastroenterology colleagues that you're not doing enough procedures to make your salary or carry your weight. So what type of liver diseases do you take care of in a community setting? Well, really the same ones or even more of a broader distribution of hepatology diagnoses than you see in the academic medical center. This is data from our Liver Institute of Virginia database from this year. Hepatitis C, which used to be 45% of all of our cases when I first started in 2010, is now down to 18%. What's increased significantly is non-alcoholic fatty liver disease, which now represents about a quarter of all the patients we see, followed by alcohol at 19%. Then there's this whole group that we rarely see in an academic medical center where we're focused on more complex problems, and these are simple abnormal liver function studies that the primary care provider doesn't really exactly know what to do with. Many of these do turn out to be fatty liver disease, but some of them turn out to be mild autoimmune or drug-related elevations in liver enzymes and many other different things. This is really a very interesting group to kind of work through and deal with. Autoimmune liver disease accompanies about 11% of the patients, and this is autoimmune PBC, sclerosine cholangitis, and their variants. We see a lot of liver masses, a lot of benign liver masses, focal nodular hyperplagias, adenomas, and we have to kind of discern what's significant and what's not significant. That's about 5% of our cases. And finally, hepatitis B, in my practice, rounds out to about 4% of the cases. This may be significantly larger on the East Coast or West Coast, which has a higher Asian and non-Asian immigrant population with hepatitis B. So overall, when you look at basic hepatology, acute and chronic stable liver disease accounts for about two-thirds of the patients we see, whereas cirrhosis is about slightly over a third of all the patients we see. We also see a lot of patients with advanced liver disease. We manage complications of cirrhosis both inside and outside the hospital. Liver cancer is about 8% of the patients in the practice, and post-transplant management accounts for about 5%. Now, as you all know from your training, liver transplantation really is a fundamental part of being a practicing hepatologist. So one of the things you want to do when you get down to a community practice is you want to reach out and develop a relationship with a liver transplant center or centers. This allows you to participate in pre-transplant care, allows you to participate in the liver transplant testing or evaluation testing for the liver, for the patient to determine if they're a candidate for a transplant. You can assist in liver cancer management by doing TACE, Y90 ablations, or radiofrequency ablations locally. And you can participate in pre-transplant monitoring and treatment of these patients when they develop decompensation-required hospitalizations prior to their transplant. However, you can also participate in post-transplant care. If you've completed a hepatology fellowship as part of your training, you know about transplant immunosuppression. You know how to adjust transplant immunosuppression, and you're perfectly capable of doing this in the community once the patient is stable and doesn't need to be seen by the liver transplant program on a frequent basis. If you have elevated liver enzymes, you can identify the etiology for this, and if it's rejection, you can treat this locally because you know the algorithm how to do that. However, of course, you want to work with closely and communicate with the transplant program about their patients. And finally, you can monitor patients for HCC recurrence. Not only there's recurrence of HCC, but what we're starting to see more and more, as you all know from your training, is an increase in post-transplant non-alcoholic fatty liver disease, which confuses the picture, is this rejection or is this post-transplant fatty liver? When I started my training and early in my career, it was always, is this recurrent hepatitis C, or is this rejection for the cause of the elevated liver enzymes? Now, everybody with hepatitis C is cured, and the question is, are those elevated liver enzymes fatty liver or rejection? Liver cancer is the only cancer in this country that is increasing in frequency. The oncologist is doing a great job at all these other cancers, identifying them, really treating them, cancer preventions, but liver cancer continues to increase in frequency. This is due to the previous hepatitis C epidemic, where many patients are cured of their hepatitis C, but now have cirrhosis and remain at risk for developing liver cancer and the current epidemic of non-alcoholic fatty liver disease. You can manage liver cancer yourself in community practice. You do not have to send these patients to oncology or to a cancer center. We do have many trained interventional radiologists who can treat hepatocellular carcinoma with TACE, Y90, radiofrequency, or microwave ablations, and you can prescribe chemotherapeutic agents, which are easy to do because they're pretty well tolerated. You can prescribe a TKI drug to treat liver cancer, such as levatinib or serafinib, or you can prescribe checkpoint inhibitors, which can be administered in institutional infusion centers. You can also participate in clinical research. Over 50% of clinical trial sites are now outside of academic medical centers. Why are pharma going outside of medical centers? Because it's reduced indirect costs. These practices can use central as opposed to institutional IRBs, which academic centers are tied to. As a result, the startup time to initiate a clinical trial is significantly less in a community setting versus an academic setting. The income you receive from clinical trials can be profit sharing to the GI group or the health system, and when you do that, you get recognition and appreciation for the revenue that you bring to the health system or your GI group. I want to finish off by talking about the financial model in community practice, very different than what you see in an academic practice. In general, your base salary in a community practice setting is based upon actual income that is derived through insurance claims or by RVUs that are generated by the clinical care you provide. The target RVU for a hepatologist appears to be about 5,000 to 5,500 RVUs annually, and the average payment per RVU that you receive is somewhere between $40 to $60. However, you can also generate bonuses in clinical practice, which are very unusual or less common, should I say, in an academic situation where you're paid straight salary based upon your years of participation in clinical rank. These clinical bonuses are for exceeding your RVU targets, for seeing more patients, providing more clinical care. For participating in clinical research, you can get a research bonus. For bonuses for supervising nurse practitioners or physician's assistants, the politically correct term now, advanced practice clinicians. Or you can receive a stipend from the liver transplant program that you're collaborating with. This data from a study that I published in hepatology that looked at the salary of hepatologists across different practice environments. I included four categories, those working in the university hospital liver transplant program, those working in a non-university hospital with a liver transplant program, those working at a university hospital without a liver transplant program, and finally, those in clinical practice. You can see the majority of respondents to this ASSLD survey were practicing at a university hospital with a liver transplant program, but that's where most hepatologists reside. So the proportions across these four categories are probably correct, and we have a pretty good representation. This shows the average ages, which happened to be a little bit higher in clinical practice. The percentage of males across the different practice environments, you can see a much higher percentage of females in the university hospital setting. This looks at the training that the hepatologist received, either internal medicine only, internal medicine with GI, or the full complement of hepatology training after GI, and the percentage of time they spent caring for liver disease, which was over 90 percent at the two liver transplant program settings, and the percentage of procedures that the hepatologist performed, which was lowest at the liver transplant hospital setting. Now, this looks at the salary comparisons that people supplied for this survey, and the average salary for a university hospital hepatologist, about $300,000 annually, and in some places they can get an additional $77,000 in bonuses. A non-university hospital with a liver transplant program, generally the hepatologist made about $100,000 a year annually more, and the highest salary was achieved by those people that identified themselves as a hepatologist in clinical practice, and the bonus structure was far greater, as you can see there. So, in summary, the practice of hepatology has matured and can now branch outside the tertiary care center or liver transplant program. ASSLD has recognized this by creating the clinical practice SIG, which was initiated in 2015. You can care for a population with diverse liver problems and disorders in the community. You can develop a relationship with the liver transplant program or programs. You can pair for patients with liver cancer, conduct clinical research, and generate an excellent income by practicing hepatology in a clinical setting. And those are the main things I've learned over the 30-plus years of my practice in hepatology in two different environments. Thank you very much for your time. Good afternoon, everyone. I'd like to thank the course organizers for inviting me to give this talk today on finding and negotiating your first job, and hopefully this will be a nice way to end the career development workshop today. A little bit about me. My name is Aparna Goyal. I'm a transplant hepatologist at Stanford University and the Associate Program Director for the GI and Hepatology Fellowship at Stanford as well. I have no relevant conflicts of interest to disclose. So, just a brief overview of what we plan to discuss today. I'll review some practical strategies to finding your first job, a general timeline that you might want to follow on your search process and negotiation process, and then some tips on what to remember when you're going through the negotiating process. The first thing is the process of finding your first job, and the finding part can seem very daunting, and it might feel comfortable for you to say, I'm going to interview at the institution I'm at, and I'm going to stay there, and not really look and search for other potential opportunities. It's important. It's important to think about where else you could potentially go. I remember when I first started the search process, it was very daunting. I honestly many times wished that it was very similar to the match process, where there would be this beautiful computer algorithm that would just tell me where my next step was going to be, because that's how my last two big moves were made, but that's not the way it works, and for good reason. So just remember that as you begin the search process, that your network is very big. You should be willing and be ready to tap into old colleagues from medical school that might be at different institutions and have positions at different institutions or at different health systems. You should be willing to talk to residency colleagues and alumni from these institutions. Your current fellowship has a big alumni network as well, and it's very helpful to contact alumni that might be at potential places that you'd be interested in joining. Remember, your network also includes mentors. These are your current mentors and your past mentors, so mentors from medical school and residency that you might not be working with anymore, but that can help you, that can help you in understanding if there are potential opportunities available to you. Remember that your fellowship program director and other faculty are also available to you, and these are faculty that are at your institution and are usually more than willing to make a phone call for you to get you a potential interviewer to understand if there's potential positions at them. And lastly, your division chief, so your fellowship division chief is obviously very well networked, and you should feel comfortable approaching them to see if there's anyone that you would like to get in contact with for opportunities. You should remember to be resourceful as well. So, you know, these are not necessarily well publicized, but there are job postings on most of our GI organization sites. So, the ASLD has a career center website where there are job postings for different positions, transplant hepatologists, non-transplant hepatologists, different practice settings, including university and non-university-based practice settings, and it's helpful to sort of scour these resources and understand, you know, based on your location preference or based on your job preference where you might be, you know, what opportunities might be worth looking into. Similarly, the American Society of Transplantation has a career center website, as does the AGA, and if you are most interested in pursuing university-based positions, most universities at the Department of Medicine website will have open faculty position sites that you should, that you can search for potential postings, and each health system will have its own way of creating these postings. The VA has separate posting sites if you, you know, Kaiser's have different posting sites as well, so it is, it's worth looking at any of these organizations that you might be interested in working at and seeing what might be available to you. This is just a very potential timeline to follow. Don't, this is not set in stone in any way, but I think it's a nice way to sort of think about the process of your last year of fellowship and how, you know, where you might want to be along the way. So, think about the first part, the first few months of fellowship as your time to update and really get things prepared. So, update your CV, look at other CVs from your alumni, from your colleagues, and have folks review your CV, have your mentors review your CV, have your program director review it. You can consider writing a brief cover letter. Sometimes these cover letters are just, you know, simply a few sentences that explain the job that you're interested in or the job that you're looking for or purely that you're interested in having a conversation with a potential employer, and that can be written in the email text itself, or if you want to draft a larger cover letter, it can be included as an attachment to these emails. You want to consider contacting potential employers and scheduling interviews in the fall and the winter period. This is an especially good time for GI because a lot of our society meetings happen at this time. So, as ASLD is happening right now, and it would be a good time to meet people and potentially have an interview or two lined up if you had contacted folks in advance. Similarly, you know, the ACG is happening in October. What happens in October usually would be a good time to potentially meet people. So, this is a nice time to, you know, either informally get to know a potential employer and what positions they might have available and to schedule some interviews around this period of time. The interviews will probably take place, you know, anywhere from the time of these meetings up until, you know, even close to the spring of your last year of fellowship. Sometimes they'll interview once or twice just to meet everyone that you might be interested in meeting in the division, and some places will ask you to schedule a talk to give to the division, sort of a job talk that describes any research that you might have done during fellowship or what your ultimate career plans are. Hopefully, you walk away and have some offer letters that you will be able to review, and that's where the negotiation process starts, and we'll talk about that next. And then lastly, once you have, you know, thoroughly negotiated your offer, you'll hopefully review and sign your contract. So, we'll spend the rest of this talk discussing negotiation, and I think this is a tough thing because many of us have never been in this position before, and we don't feel like we have the power to do it when we're leaving fellowship. Many of these tips come from Dr. Kim Brown's talk that she gave at the Career Development Workshop two years ago as well on negotiation, and it was very helpful to have her perspective as she was the chief and is often on the other side of the table. So, I'll offer some of the advice that she gave as well. So, remember, negotiation is purely the act of carrying on business. Do not take it personally, and you should not feel like it's a personal attack against you if you don't get what you want. It's a give and take process, and the goal is that at the end of it, both parties will walk away with a win. And the goal, the type of negotiation you really want to pursue is a type of negotiation called integrative negotiation, and that's when parties are cooperating to achieve maximum values by integrating their interests into an agreement. So, you want to integrate the interests of your potential employer with your interest, and that's what we call a win-win negotiation. And as you are undergoing this process, the key question will always be how can the resource that's in front of you be best utilized, and that resource is you. So, your potential employer is thinking about how can you best be utilized, and you're thinking about what is the best value that I can add to this company, to this university, to this organization. Remember, your interests are not opposed, but they might be different, and it's important. That is part of the process is coming to the agreement when your interests are different. So, the negotiation process, think of it as in four steps. The first step is preparation, and that's really what you have to spend the most amount of time doing. So, this is the process where you think about who you are, and you really need to know who you are in advance of any potential interviews that you have, and you have to research your potential employer as well. So, as you prepare, and as you think about what do you bring to the table, you should think about all of these different things that you carry along with you. So, remember that you are very well trained. Remember that you bring with you unique experiences, whether that be experiences based on your training institutions, your personal experiences, life experiences. You have a specific expertise, and potentially your research in the past has allowed for that specific expertise. Have you ever developed a program? What diversity do you bring to the university or to the potential employer? And remember that diversity can be in many different forms. It can be, you know, from where you're from, do you have children, do you have a partner, your race or gender? What are your specific interests? Are they, do you have a specific research niche? Do you have interests in quality improvement or in education? And what is your ability to mentor? So, this is the first step in the negotiation process. The second part is really sharing all this information that you're prepared. So, your employer needs to know about you, and you need to know about what your employer can offer you, and that's this information sharing piece. And the third part is bargaining. So, this is where you do that potential trade-off, and you need to focus on your priorities. So, what are you willing to give up for what you want? And this is where you potentially bring up that I really want to work part-time. I really want to work at the clinic at location X. I really want to be able to have a clinic where there's always training fellows that are rotating with me. You bring up what your priorities are, and your priorities are likely to include salary, protected time. Do you have protected time, and how does that change your appointment during your appointment? It will likely include if there's mentorship opportunities. What is the service time? What is the call like? And, you know, potentially if you have little kids, you need to factor that into consideration if you're taking call every two to three weeks. Are there opportunities for collaboration? Are there opportunities for obtaining an advanced degree like a master's in research or an MBA? And are there leadership opportunities in the division or beyond the division, in the department or at the hospital level or at the health system level? So, these are all things that you will consider, and you will prioritize, and you have to really think about what it is that's a must, and what is a want in your list, and what you're willing to give up, and what your trade-offs could potentially be. And then, finally, you'll hopefully walk away and finalize the deal, but remember to make sure you take notes at the end of every conversation that you have during your interview process and during the negotiation process. So, salary is just something I want to bring up briefly because this is always at the top of everyone's mind, and whether it should be your first priority or somewhere in the middle or your last is a personal decision. I think very frequently, it's at the top priority for the interviewee. I think for the employers, rightly so, and our chiefs, they think it's not just about salary. There's so many other things that build the perfect job offer package, and it's really important to think about all these other pieces, too. So, know the market value. Know the market for starting salaries, and there's plenty of available resources to do that online. Understand how your salary is determined, and this can be a little bit tricky. You should understand if there's an RVU structure and what the expected effort would be to meet that RVU structure, if there's incentives as well. And, again, remember to understand where salary is on your priority list. I want to bring up just one paper that was published by Michael Christ recently, this past year, of a survey of about 120 or so early-career transplant hepatologists, and reviewed base salaries, burnout, job satisfaction, and I think that as you start this process, it's worth just reviewing this to get some baseline information on what the job market is like and what most people have in terms of a clinic, an endoscopy breakdown, what their base salaries are like, too. It's just a nice little starting structure for that. And then, lastly, I just want to conclude with a few additional considerations during the negotiation process. So, it's important to understand who the decision-maker is, and is the person that you are negotiating with the decision-maker, and if not, what influence do they have in ultimately helping you make it close the deal and finalize your negotiation? Another thing to consider is how will things change over time, and if there are certain metrics that are in place for allowing those changes in time. So, at a certain point, is there a change in salary that can be expected? Is there a change in your office space that can be expected? Is there a change in protected time that can be expected based on additional funding support that comes in or just depends on how many years you've been working for? You should also talk and understand if there's anticipated changes in the division. So, is anyone planning to leave, and how does that impact your position? And the last thing, and this is something that Dr. Brown really reinforced, but I'm briefly just bringing up so you can read about it, is that you should create something that's called a BOTNA, which is the Best Alternative to Negotiated Agreement. This is something that's talked about a lot in the negotiation world. So, you essentially think about what your perfect job is that you envision. You think about your mentor, your location, your space. Is there a big window in the office? What floor are you on? All these things that sort of you envision as your perfect job, and then now think about what your acceptable job is, and your acceptable job is something that you, it is okay to say yes to, and creating your BOTNA will help you, and it'll tell you when it's okay to accept an agreement and when it's appropriate to reject the agreement. So, it's worth reading a little bit about this and creating your BOTNA as you go along this process. So, to conclude, a few key takeaways, if you can move on to the next slide. A few key takeaways is just remember, be resourceful when looking for job opportunities. Think about your entire network from the point of where you started medical training to where you are right now. Don't be shy to ask. In the interview process and the negotiation process, you will never get what you don't ask for, so it's very important to ask in advance. It's okay what you ask for cannot be delivered, but it's very important to be able to ask, and remember also that this will not be your only negotiation. Even if you choose to move forward with a job that you're interviewing at right now, you will likely renegotiate things with your employer in the future. So, it's important to practice this skill set, and then in the green box, there is just the key steps for the negotiation process, again, that I've outlined. So, prepare, prepare, prepare. That's the most important thing. Practice. Know what your values are and be able to voice your values and what your absolute musts are. Create a BOTNA. Focus on your priorities and don't lose sight of your priorities, and then lastly, lose your ego that doesn't do anything at the negotiation table. Thank you very much for your time, and look forward to any questions that you have.

academic medicine

tenure track position

structured weekly schedule

research

clinical work

mentoring

job search

negotiation strategies

networking

work-life balance

negotiation skills

hepatology

patient care