2 nd Year Fellows Conference March 22 25, 2012 Scottsdale, AZ - PDF document

Academic Clinician • Excellence in Clinical Practice–Master Clinician – Emphasis on quality and quantity of care – Innovation in delivery of care – Quality improvement – Regional reputation or recognition • Excellence in Teaching – Master Teacher – Didactic, bedside – Curriculum development, innovative teaching materials and methods – Mentoring Timeline Considerations to Assistant • How long is the course to Assistant Professor? • What is the role of 4 th yr fellowship or instructor position? • What are the implications of appointment? – Clock is started – Salary may improve – Benefits may change (improve) – Research package may be available – Responsibilities may dramatically increase Timeline and Evaluations 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 0 1 2 3 4 5 6 7 8 9 10 Instructor 1 yr review 3 yr review 6 yr review Renew! On to Assistant Nomination Professor Professor Promotion Review Associate Professor

GI Modern Family - Many Valuable Roles 18 16 14 12 10 8 Professor 6 Associate 4 Assistant 2 0 Non-Faculty Great Advice • When you come to a fork in the road, …. • It’s not the years, honey, ….. • When life gives you lemons, …. • Good ideas are a dime …. • Obstacles are the …… • It’s never crowded on ….. • Il buono, il butto, ….. • You can do it !!!

A Career in Research Binita M. Kamath MBBChir MRCP MTR March 2012 A Little About Me • Clinician-Investigator • 60% Translational Research – Inherited cholestatic diseases, esp. Alagille syndrome • 30% Clinical – Hepatology (outpatient) and Liver Transplant (inpatient) and Procedures

What is a Research Career? • Research-predominant profile • >50% time devoted to research (“protected”) – <40% seeing patients – Education, administration, leadership • Basic science, clinical, translational Why choose a research career? PASSION for the question/area you are studying DESIRE to touch the lives of people you will never meet What are you letting yourself in for? • Flexibility – The work is never finished • Salary not tied to patient #s – Dependent on grants • Rejection • Travel • Public speaking

How to start a research career 1. Passion and an Inquiring mind 2. Pertinent question 3. Time 4. Money 5. Research team Obremsky et al, J Orthop Trauma 2011;25:S124-127 How to start a research career #1 • Desire and passion • Inquiring mind • 90% perspiration, 10% inspiration • Gladwell (“Outliers”): 10,000 hour rule How to start a research career #2 • Pertinent question – who cares? • Testable – feasible and ethical • Find your niche – path to independence

How to start a research career #3-5 • Time (dedicated, not protected) • Money • Research team – research assistants, students, statistician • Negotiation The Right Institution • Mentor • Division Chief • Clinical colleagues • Researchers in the Division – track record • University How to start a research career • Find a mentor and project – First Year! • Find your NICHE • Strongly consider a Masters or PhD (if you don’t already have one)

Currency for a Research Career • Abstracts • Publications (1 st author) • Chapters, reviews – THEMATIC • Funding – institutional, foundation, NIH Establishing your Research Career • Define your expertise/skill set • Network • Collaborations • Extend beyond your institution • Consortia Time Management • Learn to say “No” • Learn when to say “Yes” • Be a good team player in your Division

Maintaining your Research Career • Sketch out your career path regularly – Research, clinical, administrative, education – Advisory committee • Thematic – Your CV must tell a story – White Board Define Goals • 3- 5 years……….10 years • Academic promotion • Make an impact • Division Chief, Section Chief, Research Director • Nobel prize Strategies and attributes of highly productive scholars • 94 highly productive scholars • Short-answer survey: 5 questions re: strategies in research writing • 56% response rate Journal of School Psychology 49 (2011) 691-720

Recommendations of highly productive scholars 1. Follow your bliss, be persistent and work really hard 2. Collaborate 3. Manage your schedule wisely and prioritize Journal of School Psychology 49 (2011) 691-720 Recommendations of highly productive scholars 4. Have protected time to write 5. Pursue a systematic line of research that cultivates your expertise 6. Stay current in the literature and become a reviewer Journal of School Psychology 49 (2011) 691-720 Recommendations of highly productive scholars 7. Take peer reviews seriously without getting defensive 8. Familiarize yourself with journals and select the right outlet 9. Get a mentor and be a mentor Journal of School Psychology 49 (2011) 691-720

Why do I Like Private Practice? JANET HARNSBERGER, M.D. SALT LAKE CITY I CAN DECIDE WHAT I WANT TO DO  SCHEDULE  PATIENT MIX  OFFICE LOGISTICS  STAFF  INCOME I CAN DECIDE WHERE I WANT TO LIVE  WHERE MY SPOUSE LIVES  WHERE MY CHILDRENS’ EDUCATION IS GOOD  WHERE I CAN ENJOY MY COLLEAGUES, FAMILY, AND SOCIAL LIFE  WHERE I CAN AFFORD A NICE HOME

MY PRACTICE IS PRIMARILY CLINICAL ON PURPOSE  I CAN FOCUS ON PROVIDING MY FAVORITE KIND OF PATIENT CARE WITHOUT WORRY THAT I AM NOT MEETING EXPECTATIONS FOR RESEARCH AND PUBLISHING  I CAN DEVELOP MEDICAL ALLIANCES IN THE COMMUNITY TO ENHANCE PATIENT CARE I HAVE CONTROL OVER COSTS AND INCOME  I CAN CHOOSE THE SIZE AND RENTAL COSTS OF MY OFFICE  I CAN WORK AS MANY HOURS AS I LIKE  I CAN HIRE THE STAFF I NEED  I CAN WORK WITH HEALTHCARE TRANSFORMATION SYSTEMS TO FIGURE OUT HOW TO FIX THE OVERWHELMING FINANCIAL MESS OF MEDICINE What’s it Like? It is like another family Needs nurtured Nurtures me It is mostly sane and pretty quiet I can educate patients and staff

Here is My Weekday Life  5:45 : wake up, get ready, have breakfast with Ric, read the paper  7- 8:30: endoscopy  9- 10 : telephone hour for patients  10-2 : see patients in the office  2- 3 : dictate letters, manage the office, couple phone calls  3- 5 : hospital rounds, extra procedures  7pm : exercise with hubby, kids, friends Is Private Practice Right for You?  Depends on your expectations and what you value  It is BIG for me to take good care of patients  I find lots of ways to be a good citizen in my professional and my regular life  The relationships you build in your communities will determine your long-term satisfaction What to Look for in a Private Practice  If you are joining an established practice, I would think you would want to be sure the aura of the practice is right for you  Type A ?  Profit oriented ?  Restrictive to future endeavors?  Who do they keep? Who do they fire?  Can you make an impact?  Time for ongoing education?

Will you Find What Your Want?  Probably!  As a group, physicians want the best for those they watch over. This includes you.

Kathleen B. Schwarz, M.D. President Ross Conference 2012  NIH  Roche/Genentech  BMS  Novartis  Vertex  Impro rove ve qualit ity of care and healt lth h outcomes for child ldre ren n with h disord rders rs of the gastro roint intestina nal l tract and liver ◦ Supporting research that advances understanding ◦ Fostering translation of knowledge into practice ◦ Serving as effective voice for children, families, and members of our profession

 Executive Council ◦ President, President-Elect, Past President, Secretary-Treasurer, 7 Councilors – Canadian, North American, Mexican  Committees: ◦ Advocacy, Clinical Care and Quality, Endoscopy, Ethics, Education and Training, Fellows, Hepatology, IBD, International, Motility, MOC Task Force, Nutrition, Obesity Task Force, Practitioner’s Task Force, Publications, Professional Education, Professional Development, Public Education, Research, Technology  National office:Margaret Stallings (Executive Director); Kate Ho; Kim Rose  ,

‘trusted intermediary who functions as your defender in your dealings, policies, standards, and procedures” Google

 Information for kids and parents  Digestive topics A – Z  Find a pediatric gastroenterologist  Featured resources – eg dangers of popular magnets!  Comic strip on how to prepare for a colonoscopy – Bowel Prep NO Sweat!  Image ge of the Mont nth  Edit itoria rials ls  Guid ideli line nes  Origina inal article icles ◦ gastro tro, hepato tology gy, nutriti rition  Case report rts/Sho hort rt communica unicatio ions ns  Selec lected summaries ries  Letters rs to the Edit itor/Notice ices  Call for papers rs – eg. Pediatric ric Gastro roent ntero rolo logy Around und the Globe

 K Ross, Course Director  Michael Narkewicz, T and E Committee  Margaret Stallings and Kate Ho,, NASPGHAN  Abbott Nutrition for  Bob Dahms ◦ Arch Curran ◦ Gary Fanjiang, MD

A path to a career in hepatology • Me • First Faculty Position Medical Student  4 th Year Rotation with Bill Balistreri  Colorado A Journey to the Liver  Passion for knowledge and clarity  Given the opportunity i.e. Asked to participate in liver clinic • Residency  Welcomed to the clinic by the whole team Bile and Beyond  Research at the bench:  Arnold Silverman and Ronald Sokol • Hepatic metabolism: partnered with local experts: Neonatology  Love and passion for GI and Liver and Patient Care Michael Narkewicz MD • Fellows  Clinical Research: Mentored by Ron Sokol wship • Philosophy: we all participated: how else will you learn! Professor of Pediatrics  Pediatric Scientist Development Program NIH Funded • Transplant: Hewit-Andrews Chair in Pediatric Liver Disease  Two years of bench research in Meudon France  Centre de Recherches sur la Nutrition University of Colorado SOM  Confession: I never saw a transplant until I was an attending!  Developmental regulation of hepatic glucokinase in newborn  I learned by apprenticeship: a great way to learn MENTOR KEY Children’s Hospital Colorado liver • Foundation for hepatic metabolism interest 2 3

Hepatology Research Hepatology Clinically What advice do I have? • Progression: • Clinical interests drew w patients • Keep your interest and skills in general GI • Developed further expertise: ERCP, viral  Found a niche or two hepatitis  Viral hepatitis: started with local experience: • Find the person wh who does liver and follow w them m • Took as mu much transplant call as I could possibly leveraged adult expertise in HBV and HCV with early around like a puppy dog do do local treatment attempts that led to publications  This led to participation in PEDS C and an • Look at every liver biopsy at your place by • Opportunity: I wo introduction to NIH staff would like you to be the director yourself of the liver center  SPLIT: PI for PTLD studies • Opportunity: Endowe wed chair  PALF • Find a niche expertise for yourself in liver • TAKE HOME ME ME MESSAGE  BARC • If you put the patient first, good things alwa ways  Finally I had to do my own work: Cystic Fibrosis • Go to The Liver Me Meeting and to the AASLD follow: w: for the patient and for you single topic conferences 4 5 6

What about that fellowship Criteria for a Training Program • Accredited by US or Canadian oversight • Certificate of Added Qualifications in Pediatric • UNOS UNOS-approved center (for US trainees) Transplant Hepatology • Pediatric LT specialist and surgeon Ped ediat atric c Tran anspl splan ant Hep epat atology ology  Began from a move in Internal Medicine to recognize the • At least 6 mo months on the IP liver service, we weekly expertise needed in transplant hepatology continuity clinic for 12 mo months  Pediatrics participated in parallel (ABP) • Other mo months: hepatology or transplant-related ≠ experience, including transplant research • Current requireme ments • direct involveme ment in pre-, , peri-, and  Boarded in Pediatric GI and participating in MOC postoperative care of at least 10 pediatric LT  1 year (12 months) of training in a program accredited for Ped Pediatric Hepatology patients training in transplant hepatology in US or Canada • direct involvement in OP management of ≥ 20 pediatric LT recipients 7 8 9

What I do know • CAQ not required by UNOS to care for transplant patients • 500 pediatric transplants per year • You wi will ma make a lot of PVUs (Patient Value Units • MA MANY MA MANY MA MANY mo more patients wi with liver or Personal Value Units) disease wh who do not need transplants • If you wa want to do hepatology: • Third Take Home me Me Message  It is great  It is rewarding • Do Wh What Ma Makes You Happy and Challenges You  It requires you to be interested and to be part of the community and You Wi Will Have a Great Career!  It has great research opportunities  It has great clinical opportunities  You will not make a lot of RVUs (Relative Value Units) from hepatology procedures 10 11

Motility: Why you will want to be a neurogastroenterologist! Carlo Di Lorenzo, M.D. Why does it matter to me? Jay Pasricha, Gastroenterology, 2011, 140:1126-8 Reasons people dislike motility • It is not about pus and blood ( is it the testing or the disease?) • Too invasive • “These squiggles do not mean anything” (no controls, not predictive, too many artifacts…) • Not trained • Booooooooring!

Why you should give motility and FGID some love… • The most important job of the gut is to “move” its contents from mouth to anus • Looks are not everything • Motility problems are common • Lots of “new gadgets” • CPT codes have been established • Your market value increases (11/13 of last job advertisements mentioned “motility”) • Aren’t we all little squiggles on the face of the earth? New gadgets Gastrointest Endosc 2011;73:949-54

Motility disorder demonstrated in: • Gastroesophageal reflux • Achalasia • Toddler’s diarrhea • Functional abdominal pain • Functional dyspepsia • Functional constipation • Intestinal pseudo-obstruction • Hirschsprung’s disease • Other g.i. neuromuscular disorders “Motility disorders” are not just about disordered motility Psychosocial factors Brain – Gut Interactions Altered motility / Gut – immune Visceral secretion interactions hypersensitivity Dogma: Motility disorders rarely have pain as the predominant symptom Fact: If you become a “motility expert”, you will be very popular among your more organically oriented “friends”, who will be more than happy to send to you all their pain predominant patients to rule out a motility disorder

Test! Emesis Interrupts the ENS Postprandial Program and Initiates Power-Propulsion Program Courtesy of Hans Jurgen Ehrlein, DVM B12 The Migrating Motor Complex (MMC) MMC phase-III activity front Manometric recording 0 5 10 15 20 25 Time ports on catheter (min) B13

P14 What do you want to be? “Motilist” vs “functionalist”  Does pathophysiology matter?  Lab vs clinical work  Do you enjoy psychology?  Love to talk to “challenging” families?  Prefer to give drugs or being a placebo? Great Role Models! Michael Camilleri Douglas Drossman Michael Gershon

You will be never out of a job! Prevalence  IBS, constipation, diarrhea, dyspepsia, and GERS:  All are common  62% report symptoms  If you are symptom-free, you are in the minority! Thompson WG et al. Dig Dis Sci 2002; 47:225 Prevalence of Functional Abdominal Pain in Children Sweden 13% Norway 6% Finland Holland 8% 3% United Germany Kingdom 2.5% 12% USA 13% Italy 10% Chitkara DK et al. Am J Gastroenterol 2005; 100:1868

Prevalence of Pediatric Constipation Canada Finland 5-10% <5% UK 5-10% Greece 10-15% Turkey Japan Italy USA 10-15% 10-20% 15-20% 5-10% Saudi Arabia 5-10% Hong Kong >20% Australia Brazil 15-20% 10-20% van den Berg MM et al. Am J Gastroenterol 2006; 101:2401 Functional disorders have an image problem Physician and patient perceptions: organic vs functional % responding “a great deal” or “very” Physician response (%) Patient response (%) Survey question Organic Functional Organic Functional Problem was serious 35 3 * 60 78 *=p<0.05 Patient was disabled 36 6 * 45 69 * Request was reasonable 67 25 * 95 100 Doctor was helpful 58 41 91 85 Satisfied with 74 67 88 81 recommendation Liked doctor/patient 61 33 * 94 94 Dalton CB, et al. Clin Gastroenterol Hepatol 2004;2:121-6.

Training!  Train in a program that has a “Motility Center”  Do research in motility  ANMS training program  Extra year of training in motility (much like in transplant) Participating programs: • Cedars-Sinai Medical Center, Los Angeles, CA • Medical College of Wisconsin (Adult ) and Children's Hospital of Wisconsin (Pediatrics), Milwaukee, WI • Nationwide Children’s Hospital, Columbus, OH (Pediatric) • Penn State Milton S. Hershey Medical Center, Hershey, PA • Temple University, Philadelphia, PA • Texas Tech University Health Sciences Center, El Paso, TX • University of Iowa, Iowa City, IA • University of Michigan, Ann Arbor, MI • University of North Carolina at Chapel Hill, NC • Wake Forest University School of Medicine, Salem, NC http://www.motilitysociety.org/pdf/ANMS_CTP_ Brochure_9.23.10.pdf Training in pediatric vs adults  Better training in adults for anorectal manometry and biofeedback, HRM, SmartPill  Better training in pediatrics for colonic manometry, impedance, antroduodenal manometry  Many psychosocial differences between children and adults (role of family)

Develop special expertise!  Upper vs lower  Epidemiology/QOL  Manometry vs transit  Pathophysiology  New diagnostic techniques  Traditional vs complementary medicine  PRO, outcome studies Take home messages • Become exposed to motility during your training (give it a chance!) • Find a good mentor • Stick with it if you like it • If you like it, it will pay off (marketability, fame, “interesting” patients, love from colleagues)

Kevin Sztam, MD, MPH Children’s Hospital Boston Pediatric GI and Nutrition hierarchy • Training – General pediatrics • Pediatric GI and Nutrition – IBD – Hepatology – Dysmotility – Transplant Nutrition – Allergic disease – Short bowel – Malabsorption syndromes Nutritional Care • Often secondary consideration • Few admissions for purely nutritional diagnoses • GI disease often drives nutritional status • Another team can manage it (dietitians, nutritionists, ICU)

Why people don’t like it • Everyone eats – who cares • Uncommon cause of medical emergency • Wide range of normal physiology accommodating varied ranges of intake • Measuring nutrient status can be challenging • We know everything already – just give enough • Other teams do manage it Why people like it • Everyone eats – wide applicability of results • Critical to many fields: GI, metabolism, surgery, endocrinology, infectious disease, public health, international health, general pediatrics, adolescent medicine, cardiology, psychiatry, neurology, molecular biology, ICU Why people like it • Even if intake is adequate, may require optimization • Opportunity to utilize knowledge of basic nutrient metabolism • We really don’t know everything • Comfortable with wide ranges of normal physiology

Training varies in Pediatric GI, Nutrition and Hepatology • Learning related to primary diagnosis • Presence of trained dietitians (ie, nutritionists) • Goal in fellowship – Understand and treat most common nutritional problems – Know when to refer • Wide range of capability among providers So much more • Few subspecialists are exposed to this knowledge base – Variety nutritional deficiencies and excess – Primary and secondary nutritional diagnoses – Treatment approaches • This basic training can lead you to leadership roles in different disciplines Roles for Pediatric GI trained physicians - Clinical • Depends on size and location of clinical program • Role is usually team leader • FTT – Outpatient FTT clinic (multidisciplinary) – Co-morbid conditions requiring long term enteral nutrition • Congenital cardiac disease • Neurologic disease • Metabolic disease • Cystic fibrosis

Roles for Pediatric GI trained physicians - Clinical • Parenteral nutrition service – Outpatient (Home parenteral nutrition service) • Coordination • Outpatient clinic – nutrition specific – Inpatient service – large center – Integrated intestinal failure and rehabilitation programs Roles for Pediatric GI trained physicians - Clinical • Children with non-GI primary diagnoses with major nutritional effects – Congenital heart disease, spastic quadriplegia, metabolic disease, cystic fibrosis • Individual/small GI practice with nutrition niche – Standard of care, alternative therapy, differences in approach Roles for Pediatric GI trained physicians - Metabolism • Nutritional assessment – Indirect calorimetry – Body composition testing (dexa scans, bioelectric impedance analysis, air displacement plethysmography) • Metabolic disease

Roles for Pediatric GI trained physicians - Obesity • Increasingly important public health issue • Pediatric origins of adult disease • Prevention • Management – Behavioral – Therapeutic – Bariatric • Nutritional issues aside from hyperlipidemia Roles for Pediatric GI trained physicians - Public health • Education – Departments of public health, school-based nutrition programs • National – national societies, nutrition guidelines, U.S. DHHS, NIH • Global health – malnutrition and chronic diseases “of excess” Roles for Pediatric GI trained physicians - Industry related • Formula companies • Food industry • Supplement industry • Part time – consultancy

Roles for Pediatric GI trained physicians - Government • Food and Drug Administration – Interacts with industry and investigators – Evaluate research, protocols, devices • NIH International program development in developing settings • Assisting development of systems for nutritional care • Developing local industry/products to support nutritional care • Nutrition education – Increase capacity to provide services – Share knowledge of systems Roles for Pediatric GI trained physicians - Research • Any and all disciplines • Usually requires cross-discipline collaboration – patients usually followed by service where primary diagnosis is categorized • Increasing demand for experts trained in research and quality improvement

Roles in Nutrition for the Pediatric Gastroenterologist and Nutritionist • Not for everyone • You could find yourself anywhere

ENDOSCOPY AS A CAREER Jenifer R. Lightdale, MD, MPH ENDOSCOPY IS… • Cool…! Fun, active • Attractive part of the “job doc” of a pediatric gastroenterologist • • Good for people who are “Good with their hands” • Also, for those who enjoy the [ fill in the blank ] of doing procedures • High tech • New toys • Satisfying way to help patients • Basically safe ENDOSCOPY IS ALSO… • Intrinsically risky • Takes practice • Constantly evolving as a technology • Different in kids from adults • Practiced often in the absence of evidence…

NEED FOR EVIDENCE BASIS • My personal primary motivation for pursuing endoscopy as a career • Bonus for me: all the other factors still apply • Lots of room for research • Lines up well with clinical research/education • From a quality perspective, provides a nice “lab” Engaging in thoughtful investigation of what you are • already doing on a daily basis • THE key to a procedural career BEST ENDOSCOPY CAREER GOALS • Not just to be good at doing something… But to be known for advancing knowledge… • So that everyone else can become better • THE BASICS * • Upon completion of fellowship, all trainees should be prepared to: • Appropriately recommend endoscopic procedures as indicated • Have explicit understanding of indications, contraindications, as well as diagnostic and/or therapeutic alternatives • Perform procedures • Safely • Completely • Expeditiously • Correctly interpret endoscopic findings • Understand how to mitigate risk…and manage complications • Acknowledge limitations of procedures and/or skills…know when to request help! *Principles of Training in Gastrointestinal Endoscopy, GIE, 1999.

ROLE OF YOUR TRAINING DIRECTOR: • An expert endoscopist and teacher who should monitor on a regular basis • Acquisition of skills • Success in defined objective performance standards • “Must be appropriately trained in the SKILLS OF PATIENCE, TACTILE (!) and VERBAL INSTRUCTION that characterize effective teachers of endoscopy..”* Ideally be actively involved in research in the field of endoscopy • Enhances the quality of the trainees • overall learning involvement…”* THE TRAINING PROCESS • There is a natural progression as trainees accrue more technical expertise and confidence. Observation • • Practicing the basics • Recognizing normal AND abnormal endoscopic findings • Learning manuevers /”tricks” • Rate of skill acquisition known to vary • Consistently – takes 100-150 procedures to be safe vs. competent • Many more (i.e. >400 colonoscopies)* to be good *Spier B, GIE, 2010. HOW DO YOU KNOW WHEN YOU’RE COMPETENT • Still a matter of HUGE controversy • Recent development of valid measures • GAGES* • CAT (Pediatric Specific) * Vassilou, Am J Surg, 2011

GAGES – COLONOSCOPY SCORESHEET G LOBAL A SSESSMENT OF G ASTROINTESTINAL E NDOSCOPY S KILLS SCORE  SCOPE NAVIGATION Reflects navigation of the GI tract using tip deflection, advancement/withdrawal and torque 5 Expertly able to manipulate the scope in the GI tract autonomously 4 3 Requires verbal guidance to completely navigate the lower GI tract 2 1 Not able to achieve goals despite detailed verbal guidance requiring takeover SCORE  USE OF STRATEGIES Examines use of patient positions, abdominal pressure, insufflation, suction and loop reduction to comfortably complete the procedure 5 Expert use of appropriate strategies for advancement of the scope while optimizing patient comfort 4 3 Use of some strategies appropriately, but requires moderate verbal guidance 2 1 Unable to utilize appropriate strategies for scope advancement despite verbal assistance SCORE  ABILITY TO KEEP A CLEAR ENDOSCOPIC FIELD Utilization of insufflation, suction and/or irrigation to maximize mucosal evaluation 5 Used insufflation, suction, and irrigation optimally to maintain clear view of endoscopic field 4 3 Requires moderate prompting to maintain a clear view 2 1 Inability to maintain view despite extensive verbal cues SCORE  INSTRUMENTATION (if applicable; leave blank if not applicable) Targeted instrumentation: evaluation is based on ability to direct the instrument to the target 5 Expertly directs instrument to desired target 4 3 Requires some guidance and/or multiple attempts to direct instrument to target 2 1 Unable to direct instrument to target despite coaching SCORE  QUALITY OF EXAMINATION Reflects attention to patient comfort, efficiency, and completeness of mucosal evaluation 5 Expertly completes the exam efficiently and comfortably 4 3 Requires moderate assistance to accomplish a complete and comfortable exam 2 1 Could not perform a satisfactory exam despite verbal and manual assistance requiring takeover of the procedure WHAT ABOUT ADVANCED PROCEDURES? • ERCP More complex and technically demanding EUS Generally carry higher risk of complications • ACHALASIA Treatment Required less frequently than standard procedures • Advanced hemostasis Manometry catheter placement • Number of individuals trained to do them can be smaller Stricturoplasty • Same rules about “numbers needed to be good” still apply Stent placement Endoscopic mucosal resection (EMR) • By the guidelines*, training in advanced procedures Endoscopic submucosal dissection (ESD) • Founded on a thorough mastery of standard procedures Enteroscopy (single vs. double balloon) • Requires year(s) of extra training beyond 3-year fellowship Endoscopic fundoplication POEM • Requires adequate patient volume AND faculty expertise *Principles of Training in Gastrointestinal Endoscopy, GIE, 1999. WHAT ABOUT ADVANCED PROCEDURES? • More complex and technically demanding • Generally carry higher risk of complications • Required less frequently than standard procedures • Number of individuals trained to do them can be smaller • Same rules about “numbers needed to be good” still apply • By the guidelines*, training in advanced procedures • Founded on a thorough mastery of standard procedures • Requires year(s) of extra training beyond 3-year fellowship • Requires adequate patient volume AND faculty expertise *Principles of Training in Gastrointestinal Endoscopy, GIE, 1999.

OPTIONS FOR ADVANCED TRAINING • Advanced/Therapeutic Fellowships • i.e. MGH/BWH, Columbia, HUP, Mayo, Cleveland Clinic, etc. • Generally aimed at adult fellows • Some precedence for training pediatric fellows • Offers high volume, structured training May also include training in statistics, epidemiology, study design • Goal is to develop “academic” physicians • • Through a MATCH process as of this June 2012* *http://www.asge.org/apps/aef/aef_main.aspx OPTIONS FOR ADVANCED TRAINING • Alliance with local adult colleagues Arrange for dedicated time to train • Coordinate with adult fellows • • May require malpractice insurance adjustments • Alliance with local pediatric expert • Ad hoc fellow vs. junior faculty position • Requires adequate patient volume to allow trainee and trainor to practice skills *http://www.asge.org/apps/aef/aef_main.aspx OTHER OPPORTUNTIES FOR LEARNING • “Hands - on” Pediatric Endoscopy Courses • NASPGHAN • NASPGHAN/ASGE at the IT&T Center • ASGE • CME • International opportunities Simulation • Nice to learn a technique BEFORE a patient needs you • to know it Computer-based • • Porcine • I ntense training for a few hours cannot substitute for repeated and persistent exposure…

ULTIMATELY • Important to understand what skills you are going to need • Align your expectations with those of the group you are joining • Firm commitment from your Division Chief (or whoever is hiring you) • Resources you will need • Adequate “protection and support” Understand procedural environment • Establish backup call options • • If joining a large group, need commitment for you to have the time • Do procedures • Learn new skills PEARLS NO MATTER WHAT YOU DO To establish yourself as an endoscopist • • Identify a niche • Thoughtfully (a priori design!) collect data on your procedures • Submit abstracts to NASPGHAN and DDW • Contribute to knowledge Make a name for yourself! • • Consider joining the NASPGHAN Endoscopy and Procedures Committee • Reviews abstracts • Develops guidelines • Produces “Hands on” education Consider joining the American Society of Gastrointestinal Endoscopy • • Career Development Awards in Endoscopy THANKS AND GOOD LUCK!

Being a Clinician-Educator: No Longer by Default Alan Leichtner, MD Abbott Conference Objectives • Understand current options for academic promotion as a clinician-educator • Evaluate scholarship in education using recognized criteria • Access resources for obtaining training • Be prepared for the future innovations in medical education Let’s Start with a Survey • Clinical work • Research • Medical education

How to be Promoted: The Dilemma of the Clinician-Educator circa 1990: History of Promotion at HMS Researcher Researcher Teacher/Clinician Researcher Clinician Educator New HMS criteria for promotion

BUSM’s Faculty Site “Extraordinary educators, clinicians and researchers” Promotion Criteria at BUSM Tracks at BUSM

What Activities Support Promotion as an Educator? (HMS) Categories Metrics Didactic Teaching Evaluation by learners or peers; increasing involvement and responsibility in courses or clinical rotations; Innovative methods that are adopted by others; Teaching about education Research Training and Numbers of mentees; Publications with trainees; Feedback from Mentorship mentees; Accomplishments of mentees Clinical Teaching and Level of teaching activities; Evaluations from mentees; Mentorship Leadership roles in education in professional societies; Direction of successful courses; Innovative teaching methods Administrative Teaching Success of programs led (popularity, evaluations, emulation) Leadership Roles Recognition Invitations to speak; Contributions to professional organizations; Funding; Roles for educational journals; Awards; Role in creating guidelines and policies; Service on grant review committees; Service as a consultant Scholarship Development of educational materials; Publications; High impact educational research Rank and Geographic Impact (HMS) Rank Geographic Impact Assistant Professor Local to Regional Associate Professor Regional to National Professor National to International Boyer’s Model of Scholarship http://academicaffairs.unca.edu/sites/academicaffairs.unca.edu/files/BoyersModel.pdf

Buzz Group or “Think, Pair, Share” HOW DO YOU ASSESS SCHOLARSHIP IN MEDICAL EDUCATION? Assignment : Think about non-research scholarly activities in medical education, e.g. curriculum, evaluation tool, simulation workshop, etc. Take one minute and come up with 3 criteria for evaluating educational activities List of Criteria for Evaluating Educational Scholarship Standards for Assessing Scholarship Glassick Criteria Clarifying Questions 1. Clear Goals Does the scholar state the basic purpose of his or her work clearly? Does the scholar define objectives that are realistic and achievable? Does the scholar identify important questions in the field? 2. Adequate Does the scholar show an understanding of existing scholarship in Preparation the field? Does the scholar bring the necessary skills to his or her work? Does the scholar bring together the resources necessary to move the project forward? 3. Appropriate Does the scholar use methods appropriate to the goals? Does the Methods scholar apply effectively the methods selected? Does the Scholar modify procedure in response to changing circumstances?

Standards for Assessing Scholarship Glassick Criteria Clarifying Questions 4. Significant Does the scholar achieve the goals? Does the scholar’s work add Results consequentially to the field? Does the scholar’s work open additional areas for further exploration? 5. Effective Does the scholar use a suitable style and effective organization to Presentation present his or her work? Does the scholar use appropriate forums for communicating the work to its intended audiences? Does the scholar present his or her message with clarity and integrity? 6. Reflective Does the scholar critically evaluate his or her own work? Does the Critique scholar bring an appropriate breadth of evidence to his or her critique? Does the scholar use evaluation to improve the quality of future work? The Audience Inter- Patient and UME GME UME professional Family Keep a Portfolio • Lectures, clinical precepting, other educational sessions, courses – Audience, Evaluations, Impact – Participation, Direction • Innovative tools for teaching and/or evaluation • Mentoring • Leadership roles – Rotation Director, Program Director, Course Director • Scholarship – Not just Research

Where to Publish • Medical education journals • Medical journals • On-line sites – MedEd Portal – ACGME Site Training as an Educator • Mentors • Academies or Medical Educator Communities • University Resources • Courses, e.g. Harvard Macy Institute • Fellowships • Advanced Degree Programs – Traditional – MEd, MMEd, MHPEd – On-line or Hybrid Trends in Medical Education • Simulation: Cognitive skills, procedures, team training, systems design • Endoscopic procedures: Simulators, live courses, hands-on courses • Project-based Learning • Team training – Crisis Management, Patient Safety and Quality • Inter-Professional Education • On-Line Resources

EXAMPLES OF NEW TECHNOLOGY IN MEDICAL EDUCATION The Digital Revolution Digital Native Digital Immigrant • • Born before 1980 Born after 1980 (Mostly Millenials) • Can speak digital, but have • Native speakers of computers, an accent, e.g. print out videogames, digital music, emails, call someone to see video cams, cell phones if they received email, bring • Prefer to receive information people into office to see a quickly, from multiple sources screen • Prefer to interact with content • Don’t understand skills of • Constantly multitasking digital native Digital Native and Immigrant coined by Marc Prensky Slide Modified from Curtis Whitehair Is the Lecture Dead or moving on-line? Khan Academy Link to Khan Academy

Not Just Wikipedia: The Wiki in Medicine - GanFyd Link to Ganfyd Medical Blogs: Ask the Mediatrician Link to Mediatrician Beyond Simulation: Virtual Environments Second Life Link to Second Life

Virtual Conference Room Virtual ICU Take Home Messages • Yes, you can get promoted as a medical educator • Non-research contributions are valued, but need to meet criteria for meaningful scholarship • Get formal training – It is available • Technology is going to disrupt education as we know it

Journals Publishing Medical Education Articles Medical Education Journals: Medical Education (IF 2.639) Academic Medicine (IF 2.631) Medical Teacher (IF 1.494) Teaching and Learning in Medicine Advances in Health Science Education Theory & Practice Journal of Graduate Medical Education International Journal of Medical Education (On-line) Specialty Education Journals: Academic Psychiatry Journal of Surgical Education Other Journals: JAMA (IF 26.309) Family Medicine (IF 1.647) BMJ (IF 11.935) Lancet (IF 32.498) Journal of General Internal Medicine (IF 2.761) Journal of Family Practice IF = Impact Factor

How to give a great talk Carlo Di Lorenzo, M.D. Why you should listen to this talk • Listening is hard work! • Simple things can make your next talk better • An expert teacher is more successful than an expert who teaches • Everyone benefits from a good talk - Audience is happier - You get invited back Effective talk • Communicate your ideas and evidence • Persuade your audience that they are true • Be interesting and entertaining • In summary, tell a story and make it a good one, build an arc • And do not worry: people do not learn from talks!

Cardinal rules • Tell them what you are going to tell them • Tell them • Tell them what you told them Show enthusiasm • Have a good attitude and smile • Your audience is more likely to remember your personal style than your content • An enthusiastic speaker can make an average talk good, and a good talk great • Ok to be anxious (adrenaline is a great drug!) Do not apologize • “I did not have time to prepare this talk properly” • “My computer broke down so I will present only half of the data” • “I do not have time to tell you about this” • “I do not feel qualified to address this audience”

The beginning You have two minutes to engage your audience: • Why should I tune into this talk • What is the problem? • Why is it an interesting problem for me? The invitation • What is the purpose of the meeting • Who is the anticipated audience (most important!) • Respect your audience • Format and time allowed • Other presentations at the meeting Preparation • Teach them something they do not know • Very last minute information • Be enthusiastic but balanced! • Not everybody loves urea cycle defects (or motility disorders)

What to put in 1) What you believe is important 2) What the audience will find interesting 3) There is no number 3 4) You do not have to tell them everything you know (even though it is sooooo important)! Preparation • Have something to say • Use slides to illustrate your points, do not decide what to say based on your slides • The problem of hand-outs (including this one) • KISS: Keep It Short and Sweet • Audience reads 3 times faster than you can speak • Slides are not a teleprompter Being seen, being heard • Speak to someone at the back of the room, even if you have a microphone on • Make eye contact; identify a nodder, and speak to him or her (better still, more than one) • Move! • Watch audience for signs of fatigue

If you are beginning to lose the audience • “Wake-up slide” • Joke • Question • Interaction with the audience • Skip complicated slides (not ideal!) The jokes Visual jokes OK in every country Dilbert does not work in Argentina

Some jokes require time The mystery of the “Sphinxter” “Do not tell bad, old or insensitive jokes; do not use jokes in front of small audiences” (Di Lorenzo, 2012 )

How to make good slides Text • Spelling and grammar – Don’t rely on built-in fools tools – Get help • Print the slides • KILL (Keep it large and legible) • Rule of fives (sixes, sevens) – Five words per line – Five lines per slide Fonts - Bad • If you use a small font, your audience won’t be able to read what you have written • CAPITALIZE ONLY WHEN NECESSARY. IT IS DIFFICULT TO READ • Don’t use a complicated font • Be consistent

Slide Structure – Good • Use 1-2 slides per minute of your presentation • Write in point form, not complete sentences • Include 4-5 points per slide • Avoid wordiness: use key words and phrases only • Names the axes of all graphs Slide Structure – Good Show one point at a time: – Will help audience concentrate on what you are saying – Will prevent audience from reading ahead – Will help you keep your presentation focused Slide Structure – Good • Make sure the slides show what they are supposed to show (no “this slide doesn’t really show it but…”) • And not more… • Take time to explain • Assume the audience is naive

Slide Structure - Bad • Do not use distracting animation • Do not go overboard with the animation • Be consistent with the animation that you use • Make sure your animation works Distracting animations CAN ≠ SHOULD Color - Good  Use a color of font that contrasts sharply with the background – Ex: blue font on white background  Use color to reinforce the logic of your structure – Ex: light blue title and dark blue text  Use color to emphasize a point – But only use this occasionally

Color - Bad  Using a font color that does not contrast with the background color is hard to read  Using color for decoration is distracting and annoying.  Using a different colour for each point is unnecessary – Using a different color for secondary points is also unnecessary  Trying to be creative can also be bad Background – Bad  Avoid backgrounds that are distracting or difficult to read from  Always be consistent with the background that you use WATCH THE DAY TURN TO NIGHT AS THE SUN SETS ON THE TOP OF THIS ONE! Are you reading my very important point or are you looking at that stupid animation?!?. 32

Rehearse • Check length, contents, flow • By yourself and in front of audience that can give honest and constructive feedback • Print the slides and read them • Do not have to accept every suggestion (you know the topic better than anybody else) Travel • Bring back up • E-mail it to yourself • Do not check it in (same for good clothes if the talk is same day or early AM on day after) • Laptop allows very last minute changes (experienced presenters) Day of the presentation • Be rested • Dress up comfortably • After you have given the presentation to the organizers, review it one more time • Check the room and the set-up • Water • Bathroom

Presentation • Do not read • Translators (allow them time to catch up) • Timing of slide entrance (ok to keep a copy of your slides at the podium) • No fancy fade ins • No really, don’t The end • Closing slide • Closing comments (thank audience and person for asking the question) • Questions: - When to repeat the question - Uninterpretable (or stupid) questions – escape routes - When you do not know the answer • Disconnect your microphone! Mistakes to avoid • DO NOT read your slides • DO NOT stand behind the podium • DO NOT dress casually • DO NOT face the screen • DO NOT use too many acronyms • DO NOT shake the laser pointer (not a lightsaber!) • DO NOT use casual language (thing, stuff, just, cool, you guys…)

Summary • Be enthusiastic, clear and loud! • Keep it simple • Be consistent • Practice • Do NOT exceed the time limit • Have fun!

Non NIH Funding for the Junior Faculty Member Mitchell B. Cohen, MD Professor and Vice Chair of Pediatrics Director, Gastroenterology, Hepatology and Nutrition Cincinnati Children’s Hospital Medical Center CCHMC Sources of External Funding Fiscal Year 2011 State 1% Other 6% Federal Industry 86% 7% CCHMC Sources of Federal Funding Fiscal Year 2011 National Institutes of Health (NIH) 110,775,374 Agency for Healthcare Research and Quality(AHRQ) 13,604,616 Health Resources & Services Administration(HRSA) 5,133,213 Centers for Disease Control (CDC) 3,458,165 Department of Defense Army (DOD) 2,286,752 Substance Abuse & Mental Health Service Admin(SAMHSA) 686,229 Food & Drug Administration (FDA) 538,853 Administration on Developmental Disabilities(ADD) 502,327 Department of Education(DOED) 189,241 Department of Health and Human Services(DHHS) 157,626 Department of Labor(DOL) 94,190 National Science Foundation(NSF) 37,542 Total 137,464,128

CCHMC Sources of NIH Funding Fiscal Year 2011 National Heart Lung & Blood Institute (NHLBI) 27,194,368 Nat’l Inst. of Allergy and Infectious Disease (NIAID) 15,597,771 Nat’l Inst. of Diabetes and Digestive & Kidney Disease (NIDDK) 15,359,053 Nat’l Inst. of Child Health & Human Development (NICHD) 12,588,512 Nat’l Inst. of Neurological Diseases and Stroke (NINDS) 8,140,455 National Cancer Institute (NCI) 6,496,551 Nat’l Inst. Of Arthritis and Musculoskeletal and Skin Disease (NIAMS) 6,118,479 Nat’l Inst. of Environmental Health Sciences (NIEHS) 3,790,497 National Institute of Mental Health (NIMH) 3,520,469 Nat’l Inst. of General Medical Sciences (NIGMS) 2,723,720 National Center for Research Resources (NCRR) 2,621,625 Nat’l Inst. on Deafness & Other Communication Disorders (NIDCD) 2,418,618 National Eye Institute (NEI) 2,395,459 National Institute of Aging (NIA) 770,865 National Institute of Dental Research (NIDR) 526,481 National Library of Medicine (NLM) 268,600 National Institute of Nursing Research (NINR) 147,317 National Institute of Biomedical Imaging and Bioengineering (NIBIB) 96,534 Total 110,775,374 CCHMC Foundation and Other Agency Awards Fiscal Year 2011 Cystic Fibrosis Foundation 744,660 Charley’s Fund 664,148 American Heart Association 546,500 Hamilton County Public Health 459,088 March of Dimes 402,954 Crohn’s & Colitis Foundation of America 355,887 The Hospital for Sick Children 266,882 Robert Wood Johnson Foundation 265,299 American Cancer Society 230,000 The American Bd. of Med. Spec. Research & Educ. Fdn. 219,654 The Leukemia and Lymphoma Society 218,271 Cancer Free Kids 215,000 Miscellaneous Other (88) – average ~60K/award 5,193,270 Total 9,781,613 A personal funding journey: NIH funding • Individual NRSA, NIDDK "E. coli heat-stable toxin: Gastrointestinal receptor response." (DK 07790), July 1986- June 1988, $66,000 • Clinical Investigator Award, NIDDK "Regulation of ST action: Human intestinal ST receptor." (DK 01908), July 1989- June 1994, 75% effort, $374,600 • NIH: Expression and function of the guanylin ligand family. RO1 DK47318 1995-2011

• T32 DK07727, Program Director: MB Cohen, Training Program in Pediatric Gastroenterology and Nutrition: 5% effort; 07/01/05 - 06/30/15 $2,009,290 • DK058701 Studies on intestine-enriched transcription factor, IKLF (20% effort) 09/01/2001 - 06/30/2006, MB Cohen, PI • Regulation of gastrointestinal eosinophils (NIH: DK 45898-01), (P.I.: M. Rothenberg, MD, Ph.D.) 09/01/99 - 08/30/04 $1,095,267, Co-investigator, 5% effort, 09/01/99 - 08/30/00 $207,366 • R24 DK 064403, Cincinnati DDRDC: Center for Growth and Development (CGD), 04/01/03-03/31/08, MB Cohen, PI (15% effort) • NIH:P30 DK 0789392 07/01/07-05/31/12 Role: Program Director (7/1/07-5/31/09), Associate Director 6/1/09-05/31/12) Digestive Health Center: Bench to Bedside Research in Pediatric Digestive Disease • NIH: Test kit to quantify fat absorption in cystic fibrosis. (R42 DK 48537), (M. Janghorbani, PI), $388,817; Co-investigator, 15% effort, 11/01/96-10/30/98 (subcontract $120,503) • NIH: Biomedical Research Support Grant (RR 05535) Enteroaggregative Escherichia coli heat stable toxin, May 1991 - March 1992, $11,000 • NIH: Biomedical Research Support Grant (RR 05535): Localization of guanylin and the E. coli heat stable enterotoxin receptor by in situ hybridization, December 1992 - September 1993, $7,500. • NIH: Test kits for measuring malabsorption in cystic fibrosis. (R41 DK 48537), (M. Janghorbani, PI), 5% effort, $100,000, subcontract, 9/30/94-9/29/95, $30,350. • NIH: Development of accurate test kits for malabsorption. (R43 DK 48190), (M. Janghorbani, PI), 7% effort, $79,324, subcontract, 9/30/94-3/31/95, $10,000. B orderline pancreatic function in cystic fibrosis. (R43DK55924-01A1), (M. Janghorbani, PI), • $91,415; Co-investigator, 5% effort, 06/01/00-05/31/01 (subcontract $30,000) • NIAID-DMID-94-29: N01-A145252: Evaluation of control measures against human infectious diseases other than AIDS. Co-investigator. (GM Schiff, PI.), MB Cohen Coinvestigator: 25% effort, 1994-2002, $11,374,000 • DMID Protocol # 07-0052 A Randomized, Double-blind, Placebo-controlled Dose Escalation, Inpatient Phase I Study to Determine the Safety and Immunogenicity of a Single Oral Dose of a Combined Enterotoxigenic E. Coli (ETEC)-Cholera Vaccine (Peru 15 pCTB) in Healthy Adult Subjects, 30% effort, 11/1/07-5/30/10 • NIH: NIAID-DMID-N01-AI-25459: Evaluation of control measures against human infectious diseases other than AIDS. Co-investigator. (David Bernstein, PI.), MB Cohen PI of Enteric Vaccine: 30% effort, 6/1/02-5/31/07; 10% effort 11/1/07-10/31/12. • DMID Protocol 09-0066; Phase I Study to Determine the Safety and Efficacy of an Oral ETEC Candidate Vaccine, Attenuated, Recombinant Double Mutant Heat- Labile Toxin (dmLT) from Enterotoxigenic Escherichia coli, 20% effort

Non-NIH funding • American Gastroenterological Association – Supplemental Research Training Award, July 1985- June 1986, $7,500 – Industry (Glaxo) Scholar Award, "Regulation of ST-induced intestinal secretion," July 1988- June 1991, $75,000 – Research Preceptorship, Michelle R. Ritter, Summer Student, May 1989- August 1989, $1,500 – Mentor, AGA Senior Fellowship Research Award to Dr. Glen Lewis, July 1993-June 1994, $7,500. – AGA Summer Undergraduate Research Fellowship to Noeet Elitsur, ($4000), 2003 – Sponsor/Mentor: Praveen Goday 1999-2001 ($72,000) – Sponsor/Mentor: Jeffrey Rudolph, MD 2000-2002 ($72,000) • ALF: – Mentor, American Liver Foundation Award to Dr. Jane Balint, July 1994-June 1995, $7,500. • AstraZeneca – Unrestricted Educational Grant 1999, $3,995 • Avant Immunotherapeutics – Choleragard planning grant, MB Cohen PI $10,000 07/01/06-06/30/07 • Bristol-Myers – "Intestinal receptor for E. coli heat-stable enterotoxin: Increased receptor density and potential role as a receptor for an intestinally active growth factor in perinatal life," July 1989- June 1990, $9,000. – Principal Investigator: Safety and Efficacy of Rice Based Oral Rehydration Solution. January 1990- March 1993, $111,120 • CCHMC – Regulation of STa-induced intestinal secretion.“ Trustee Award, July 1988-June 1991, $92,000 – Translational Research Initiative, $3,000 DDRC Retreat, 2002 • Cystic Fibrosis Foundation – Expression and function of the guanylin ligand family (P978), July 1, 1995-July 1, 1996. $32,493. – First Year Clinical Fellowship Sponsor (Jeffrey Rudolph), (Rudolp97B0), 1997-98 ($30,500) – Fellowship Sponsor (Stephen Guthery), (GUTHER99B0), 1999-01 ($76,000) – Fellowship Sponsor (Valerie McLin (MCLIN01B0) 2001-3 ($84,500) – Clinical Fellowship to Nissa Erickson (ERICKS03B0)July 1, 2003-June 30, 2004 $42,000 – First Year Fellowship Award (Pasternak PASTER05B0) 7/1/05-6/30/06) 7/1/05-6/30/06 $42,000 • Marion Merrell Dow Foundation – Transgenic models of cardiovascular disease: Guanylin overexpression in transgenic mice, 1994, $2,000 – Transgenic models of cardiovascular disease: Targeting of the guanylin gene, 1996 ($4600) – Transgenic models of cardiovascular disease: Targeting of the uroguanylin gene, 1997 ($4600) • Mead Johnson Nutritional Group – Development of accurate test kits for malabsorption. Project 8538. September 1994-September 1995. $24,000 • Miles Pharmaceutical Company: – Prospective, controlled double blind randomized comparison of ciprofloxacin vs trimethoprim/sulfamethoxazole vs placebo for prevention of traveler's diarrhea. Jeff Heck, Principal Investigator; Responsible for Component III:Escherichia coli pathogen assays, February 1990- May 1992, 5% effort, $79,100 – Prospective, double-blind, randomized comparison of Ciprofloxacin 500 mg daily for 3 days vs. trimethoprim- sulfamethoxazole 160/800mg twice daily for 5 days for the empiric therapy of traveler's diarrhea. (Jeff Heck, Principal Investigator), Responsible for Component III, Escherichia coli pathogen assays, October 1992- April, 1993, 5% effort, $26,259. • Procter and Gamble Company – Escherichia coli pathogen assays. February 1993-February 1994. $80,000. – Efficacy of bismuth subsalicylate in decreasing stool output in children with short bowel syndrome or intestinal aganglionosis. September 1994- September 1995, $25,000 – Fellowship Research and Education, 1997-1998, $5,000 – Unrestricted Educational Grant, 1998, $2,400 – Bifido 624 in Prevention of Day Care Diarrhea, MB Cohen, PI 06/15/02-10/15/03 $367,000

• Ross Laboratories – Unrestricted educational grant: Infants with rectal bleeding: Defining allergic colitis and the role of eosinophils., (P.I.: J. Schwimmer MD (Fellow)), Faculty Investigator, %Effort: no salary support, 09/01/99-08/31/00 Direct $15,000 • Salix – 7/1/05-12/1/05 Susceptibility of diarrheagenic E. coli from US subjects to rifaximin $3000 • Solvay Pharmaceuticals – Fellowship Research and Education, 1997-1999. $25,000 – Unrestricted Educational Grant, 1999, $2,956 • Synsorb Biotech – Title: SYNSORB Pk for the Prevention of HUS in Children (PK001) and A Nested Study of the Efficacy and Safety of SYNSORB Pk in the Treatment of Uncomplicated VTEC Gastroenteritis in Children (PK001A), 08/12/99 - 08/11/00 $73,430 May need help to stand on your own Why apply for non-NIH Funding? • Gets YOU on the playing field – Provides more targeted award – written for YOU • Career development – time limited opportunity • Focused area – more specific to your research – Designed to help you get NIH funding and/or leverage your NIH money (additional trainees, specific supplies, etc) – Offers better pay line (not always) – Bolsters institutional confidence (and yours) in the initial investment – Gets you known by those in the field – Gives practice at organizing (thoughts and administrative details) for NIH grant – Not everyone plans (wants) to get an NIH grant

“Negatives” • Usually smaller grants – less ROI • Usually less indirect costs • Sometimes cannot keep all or some of the award with NIH award • Not always easier to get than NIH award • Round peg – square hole (does a colleague agree it is written for YOU) • If professional society – usually need to be a member. • Bottom line, be aware of limitations but NON-NIH funding SHOULD be part of your portfolio. Non-NIH Sources of Funding: Federal • Office of Orphan Products Development – Clinical development of products for use in rare diseases or conditions. The products can be drugs, biologics, medical devices, or medical foods. – http://www.fda.gov/ForIndustry/DevelopingProductsforRareDiseases Conditions/WhomtoContactaboutOrphanProductDevelopment/default .htm • DOD- Department of Defense – Focus varies by congressional mandate (congressionally directed medical research programs), e.g, genetics of food allergy – http://cdmrp.army.mil/funding/default.shtml – http://www.darpa.mil • CDC-Centers for Disease Control and Prevention – May have separate set asides, e.g, IBD – http://www.grants.gov/ • AHRQ - Agency for Healthcare Research and Quality – Comparative Effectiveness – Prevention and Care Management – Health Information Technology – Patient Safety – Innovations/Emerging Issues – Can use local QI or national QI networks as springboard for grant applications – http://www.ahrq.gov/fund/ragendix.htm

• HRSA -Health Resources and Services Administration – HRSA makes grants to organizations to improve and expand health care services for underserved people. – http://www.hrsa.gov/grants/apply/index.html Foundation • NASPGHAN Foundation – http://www.naspghan.org/wmspage.cfm?parm1=664 • NASPGHAN Foundation in Office Member Grant for Development of Patient Education Prototypes Patient education in practice settings. The Foundation will award up to two grants, each ranging from $500 - $2000. NASPGHAN Foundation Young Investigator Development Awards $75,000 per year for two years; 70% protected time to conduct the proposed work. 1. NASPGHAN Foundation/George Ferry YIA 2. NASPGHAN Foundation/Nestlé Nutrition YIA 3. NASPGHAN Foundation/Crohn’s and Colitis Foundation of America YIA • NASPGHAN Foundation Fellow to Faculty Transition Award in Inflammatory Bowel Disease Senior pediatric gastroenterology fellows -additional clinical and research expertise in pediatric IBD.

• NASPGHAN Foundation/TAKEDA Pharmaceuticals North America Research Innovation Award Two-year grant for innovative, high-impact research in pediatric gastroenterology, hepatology and nutrition. Applicants at any career level may apply. • NASPGHAN Foundation/ASTRAZENECA Research Award In Peptic Ulcer Diseases (offered in even numbered years) Epidemiology, pathogenesis, natural history, genetics, diagnosis and management of peptic diseases affecting children. AGA/AGA Foundation/FDHN http://www.gastro.org/aga-foundation/grants 2012-13 AGA Research Foundation Awards - At a Glance Eligible Award Amount Term # of Application Start Award Name Category Awards Deadline Date AGA-Takeda Research Scholar Award in Development $120,000 2 Career Extended to years 1 7/1 Gastroesophageal Reflux Disease 1/13/2012 2 Career Research Scholar Award (RSA) Development $120,000 years TBD 9/7/2012 7/1 * R. Robert and Sally Funderburg Research Established Investigators $100,000 2 years 1 8/31/2012 1/1 Award in Gastric Cancer Career AGA- Emmet B. Keeffe Award in Development $70,000 1 Translational or Clinical Research in Liver year 1 2/3/2012 7/1 Junior Disease Faculty Career Development $25,000 1 Elsevier Pilot Research Award year 1 1/13/2012 7/1 Established Investigators June & Donald O. Castell, MD Esophageal Career Development $25,000 1 year 1 1/20/2012 7/1 Clinical Research Award AGA/AGA-Broad Foundation Student Student 1 10** $2,500 24*** 3/23/2012 7/1 Research Fellowship Awards Award year AGA - Horizon Pharma Fellow Abstract DDW Travel $1,000 Travel 3 3/09/2012 7/1 Prizes Student $500 8 AGA - Horizon Pharma Student Abstract DDW Award 2/24/2012 7/1 Prizes Travel $1,000 3 Travel Award Moti L. and Kamla Rustgi International DDW Travel Award $500 Travel 2 3/09/2012 7/1 Travel Awards Research Scholar Awards 2003 AGA Foundation Research Scholar Award Recipients AGA Foundation Research Scholar Award Recipients 1993 AGA Foundation Research Scholar Award Recipients 1984 – Present Paul Dawson, MD Srisaila Basavappa, PhD David Polk, MD Ezra Burstein, MD Lauren Gerson, MD 1984 AGA Foundation Research Scholar Award Recipients Menno Verhave, MD Holger Kulessa, PhD Nathan Bass, MD, PhD Eugene Chang, MD 1994 AGA Foundation Research Scholar Award Recipients Hiroshi Nakagawa, MD, PhD Robert Schwabe, MD Gordon Luk, MD Sheila Crowe, MD Gianrico Farraugia, MD James Madara, MD Laurence Miller, MD Herbert Gaisano, MD 2004 AGA Foundation Research Scholar Award Recipients Andrew Chan, MD Jean-Pierre Raufman, MD Joanna Groden, PhD Steven Powell, MD Sushovan Guha, MD, PhD Joseph Sellin, MD Richard Weinberg, MD Chin Hur, MD Zhiping Li, MD Michael Wolfe, MD 1995 AGA Foundation Research Scholar Award Recipients Yuriko Mori, MD, PhD Frank Anania, MD Mary Rinella, MD Bobby Cherayil, MD 1985 AGA Foundation Research Scholar Award Recipients Adnan Said, MD Nicholas Davidson, MD Thomas Judge, MD David Perlmutter, MD Nourredine Lomri 2005 AGA Foundation Research Scholar Award Recipients Andrea Todisco, MD We are the 10%. James Reynolds, MD Michael Choi, MD Mitchell Schubert, MD Chris Yun, PhD Ariel Feldstein, MD George Wu, MD, PhD Sarah Glover, DO 1996 AGA Foundation Research Scholar Award Recipients Martha Harding, DVM, PhD Fred Askari, MD, PhD 1986 AGA Foundation Research Scholar Award Recipients Elyanne Ratcliffe, MD David Brenner, MD Martin Beinborn, MD Noah Shroyer, PhD Richard Benya, MD Andrew Leiter, MD, PhD Daniel Kessler, PhD 2006 AGA Foundation Research Scholar Award Recipients Julian Walters, MD Robert Marks, MD Claudia Andl, PhD Walter Smalley, MD 1987 AGA Foundation Research Scholar Award Recipients Kenneth Hung, MD, PhD Nancy Van Houten, PhD Serhan Karvar, MD Lee Kaplan, MD, PhD David Wang Sarah Keates, PhD Darryl Daugherty, MD Lyman Bilhartz, MD Eric Lemmer, MD, PhD 1997 AGA Foundation Research Scholar Award Recipients Akhil Maheshwari, MBBS, MD John Lake, MD Nadia Ameen, MBBS Shumei Song, MD, PhD Ginny Bumgardner, MD, PhD 1988 AGA Foundation Research Scholar Award Recipients Kenneth Yu MD Ian Crispe, MD John Barnard, MD Karen Hall, MD, PhD 2007 AGA Foundation Research Scholar Award Recipients Mitchell Cohen, MD Klaus Kaestner, PhD Neena Abraham, MD Bernard Davis, MD Hoda Malaty, MD, PhD Michael Beyak, BSc, MD Samuel Klein, MD Joseph Pisegna, MD Sean Koppe, MD Norman Sussman, MD Mark Worthington, MD Scott Magness, PhD John Wiley, MD Olga Mareninova, PhD 1998 AGA Foundation Research Scholar Award Recipients Geoffrey Nguyen, BA, MD 1989 AGA Foundation Research Scholar Award Recipients Kris Steinbrecher, PhD Victor Ankoma-Sey, MD Gregory Fitz, MD Michael Bates, MD, PhD Kevin Mullen, MD Seema Khurana, PhD 2008 AGA Foundation Research Scholar Award Recipients John Samuelson, MD, PhD Yuko Akiyama, MD Rudra Rai, MD Carol Semrad, MD Branko Stefanovic, PhD Edda Fiebiger, PhD Steven Weinman, MD, PhD Shie-Pon Tzung, MD Lara Gawenis, PhD Vincent Yang, MD, PhD Pradipta Ghosh, MD 1999 AGA Foundation Research Scholar Award Recipients Richard Saad, MD Kirsten Sadler-Edepli, MMSc, PhD Patrick Abrahams, PhD 1990 AGA Foundation Research Scholar Award Recipients Michael Volk, MD, MSc Kevin Behrns, MD James Goldenring, MD, PhD Jay Horton, MD 2009 AGA Foundation Research Scholar Award Recipients Janet Larkin, MD Lewis Roberts, MD Steven Lidofsky, MD, PhD Gregory Austin, MD, MPH Horst Weber, MD Mark McNiven, PhD Michele Battle, PhD Rohit Loomba, MD, MHSc 2000 AGA Foundation Research Scholar Award Recipients Iryna Pinchuk, PhD 1991 AGA Foundation Research Scholar Award Recipients Andrew Feranchak, MD Dorsey Bass Hiromi Gunshin, PhD Andrew Tai, MD, PhD James Corasanti, MD, PhD Nicola Jones, MD, PhD 2010 AGA Foundation Research Scholar Award Recipients Raymond Dubois, MD, MPH James Lillard, PhD Ian Corbin, PhD Steven Freedman, MD, PhD David Rudnick, MD Ype deJong, MD, PhD Loyal Tillotson, MD, PhD Anne Wolf, MD Porfirio Nava-Dominguez, PhD Kenneth Olive, PhD 2001 AGA Foundation Research Scholar Award Recipients 1992 AGA Foundation Research Scholar Award Recipients Andres Roig, MD Terrance Barrett, MD Shrikant Anant, PhD Catherine Rongey, MD, MSHS Charles Baum, MD Rebecca Chinery, PhD Anisa Shaker, MD Alice Chow, MD Ngoc-Duyen Dang, MD David Cistola, MD, PhD James Gorham, MD, PhD 2011 AGA Foundation Research Scholar Award Recipients Steven Cohn, MD, PhD Jan-Michael Klapproth, MD Ashwin Ananthakrishnan, MD, MPH Richard Hodin, MD Michelle Southard-Smith, PhD Carla Coffin, MSc, MD Karl Houglum, MD Karen Edelblum, PhD Ciaran Kelly, MD 2002 AGA Foundation Research Scholar Award Recipients Anne Henkel, MD Dominic Nompleggi, MD, PhD Willemijintje Hoogerwerf, MD Sherry Huang, MD 2012 AGA Foundation Research Scholar Award Recipients Don Rockey, MD Phillip Tarr, MD Braden Kuo, MD Kara Gross Margolis, MD Brent Upchurch, MD Konstantinos Lazaridis, MD Robert Schwartz, MD, PhD Charles Madden, PhD Shehzad Sheikh, MD, PhD Chinweike Ukomadu, MD, PhD

• Gates Foundation http://www.gatesfoundation.org/grantseeker/Pages/d efault.aspx • Thrasher Foundation - pediatric medical research – Al Thrasher Awards: 3yrs, up to $400,000. Median award is $230,000, with most between $150,000-$300,000. – Early Career Awards are limited to a maximum of $25,000 in direct costs, plus up to 7% indirect costs. 2 years. – http://www.thrasherresearch.org/ • ACG Institute - http://gi.org/acg-institute/ – Junior Faculty Development Grant $225,000 ($75,000 per year for each of three years) is to assist promising clinical researchers to develop research and careers that have a direct bearing on clinical gastrointestinal practice – Clinical Research Award – Clinical Research Award Pilot Projects – Smaller Programs Clinical Research Award • CF Foundation- http://www.cff.org/ – Basic and clinical research grants, Fellowships • CCFA http://www.ccfa.org/ – Career Development Awards: – Up to $90,000 per year, 1-3 years • Research Fellowship Awards • Scientific Conferences and Workshops • Senior Research Awards • Student Research Fellowship Awards • March of Dimes – http://www.marchofdimes.com/professionals/grants.html – Basil O'Connor • Junior faculty who do not yet have an R01. K08 is OK. Award is $150,000 over 2 years ($75,000 annually). – Prematurity Grant Program

• Burroughs Wellcome Career Award for Medical Scientists – http://www.bwfund.org/pages/52/Grant-Programs/ – Career Awards for Medical Scientists – open to MDs and MD/PhDs. People should have 3-5 papers. Award is $700,000 over 5 years. • Broad - http://broadmedical.org/ – Strong potential of clinical applicability for IBD in the foreseeable future. Rolling deadline. • Industry – Investigator initiated – Sponsor initiated • Directly related to your area of focus (or emerging focus) • Budget adequate to cover your costs without risk • ?Profit to help pay for unfunded research • Is it doable – can you enroll the patients? • Will it compete with other demands for your time? • Is it scientifically worthwhile? • Will it bring an opportunity to your patients/your center? Think Local • Local – Your institution • Trustee • Procter Scholar • K12 • CTSA PF • Digestive Health Center PF • Other Center PF

NIH Early Career Funding Judith Podskalny, Ph.D. Division of Digestive Diseases and Nutrition, NIDDK NIH Predoc Fellowships Medical Graduate * Loan Repayment School School Independent Residency Specialty Postdoc Jr. Faculty Investigator Fellowships Career Awards R-series 2nd Yr Pediatric GI Fellows , 2012 Mentored Career Development Awards (Ks)  K01 – Mentored Research Scientist Development Award (NIDDK uses for PhDs)  K08 – Mentored Clinical Scientist Development Award  K23 – Mentored Patient-oriented Research Career Development Award  K25 – Mentored Quantitative Research Career Development Award  K99/R00 – Pathway to Independence Award 2nd Yr Pediatric GI Fellows , 2012

BEFORE submitting a K-application:  Have a position at an institution that allows you to apply  Pick appropriate mentors  Publish at least 1-2 papers Funding  Generate your own preliminary data Opportunity Announcement  Identify the correct FOA  Be a U.S. citizen, permanent resident, OR have applied for permanent residency 2nd Yr Pediatric GI Fellows , 2012 for all mentored Ks:  U.S. institutions only  3 – 5 yrs, not renewable  Minimum 9 calendar months (75% effort) required 2nd Yr Pediatric GI Fellows , 2012 ‘Pathway to Independence Award’ : K99/R00 is exception:  Does not require citizenship/perm. res.  Cannot have a faculty appointment and must have no more than 5 yrs research experience  To move to R00 phase, must have a ‘tenured’ faculty position (R00 is not guaranteed)  K99 = 1 – 2 years  R00 = 2 – 3 years 2nd Yr Pediatric GI Fellows , 2012

…refer to the ‘parent announcement’ website for current FOAs for all Ks: http://grants.nih.gov/grants/guide/parent_announcements.htm …refer to the NIH K awards table for salary information: http://grants.nih.gov/training/careerdevelopmentawards.htm 2nd Yr Pediatric GI Fellows , 2012 K award includes:  Salary, with additional fringe benefits (NIDDK = $90,000 plus fringe at institution’s rate)  Research support for tech support, supplies, travel, courses, animals, patient costs, etc. (NIDDK = $25,000 for K01, K08; $50,000 for K23 if justified)  average 5 yr award, at $150,000/yr = $750,000 Elements evaluated in a K application:  Candidate = Principal Investigator  Career Development Plan/Career Goals & Objectives  Research Plan  Mentor(s), Co-mentor(s), Consultant(s), Collaborator(s)  Environment & Institutional Commitment to the candidate 2nd Yr Pediatric GI Fellows , 2012

Elements evaluated in a K application:  Candidate  Career Development Plan/Career Goals & Using letters of recommendation, Biosketch, candidate’s statement, reviewers evaluate Objectives potential to become independent investigator  Research Plan and leader in proposed area of research  Mentor(s), Co-mentor(s), Consultant(s), Collaborator(s)  Environment & Institutional Commitment to the candidate 2nd Yr Pediatric GI Fellows , 2012 Elements evaluated in a K application:  Candidate  Career Development Plan/Career Goals & Objectives Reviewers look at plans to evaluate progress  Research Plan towards independence, additional specialized  Mentor(s), Co-mentor(s), Consultant(s), training, faculty development, grant writing workshops, etc. Collaborator(s)  Environment & Institutional Commitment to the candidate 2nd Yr Pediatric GI Fellows , 2012 Elements evaluated in a K application:  Candidate  Career Development Plan/Career Goals & • Significance Objectives • Innovation  Research Strategy • Approach ..appropriate to applicant’s background and  Mentor(s), Co-mentor(s), Consultant(s), level of expertise; hypothesis driven with Collaborator(s) preliminary data; merit of research question; design and methodology  Environment & Institutional Commitment to the candidate 2nd Yr Pediatric GI Fellows , 2012

Elements evaluated in a K application:  Candidate  Career Development Plan/Career Goals & previous mentoring experience, expertise in Objectives area of research, productivity, relevance of mentor’s statement/plan to candidate’s  Research Plan strengths and areas to develop  Mentor(s), Co-mentor(s), Consultant(s), Collaborator(s)  Environment & Institutional Commitment to the candidate 2nd Yr Pediatric GI Fellows , 2012 Elements evaluated in a K application:  Candidate  Career Development Plan/Career Goals & protected time, space, opportunities for Objectives collaboration, intention to integrate candidate into research program, position NOT  Research Plan contingent on getting K-award  Mentor(s), Co-mentor(s), Consultant(s), Collaborator(s)  Environment & Institutional Commitment to the candidate 2nd Yr Pediatric GI Fellows , 2012 Common problems with K- applications:  Unclear or missing hypothesis  Overly ambitious  Unclear future plans (i.e. where will the research lead)  Inadequate career development plan  Poorly written  Inadequate grasp of the literature  Technical issues (incorrect model/cell line, not using best methods, “technique in search of a project”, etc.)  No power analysis for sample size  Mentors lack correct expertise  “Pedestrian” 2nd Yr Pediatric GI Fellows , 2012

2011 NIH K Awards* : New Awards Applications (Success Rate) Total Awards K08 489 143 (29%) 929 K23 648 174 (27%) 967 K99 878 151 (17%) 305 * approx., not finalized for FY11 2nd Yr Pediatric GI Fellows , 2012 Loan repayment programs.. Loan Repayment Programs • Five different LRPs – must pick ONE  Clinical Research LRP  Clinical Research LRP  Clinical Research LRP for Individuals from disadvantaged backgrounds  Pediatric Research LRP  Pediatric Research LRP  Health Disparities Research LRP  Contraception and Infertility Research LRP 2nd Yr Pediatric GI Fellows , 2012

NIH Loan Repayment Allocations FY 2010 [TOTAL = $75.5 million] $80 Clinical/Disadvantaged $70 Bkgd. Contraception/Infertility Dollars (in millions) $60 $16 Health Disparities $50 Pediatric $40 Clinical $30 $45 $20 $10 $- 2nd Yr Pediatric GI Fellows , 2012 LRP ‘features’:  Provides up to $35,000 per year for 2 years towards repayment of educational loans  NIH pays the taxes on this amount directly to the IRS  May re-compete (i.e., get 4 or even 6 years) 2nd Yr Pediatric GI Fellows , 2012 Eligibility:  US citizen or permanent resident  Owe more than 20% of yearly salary  as bona-fide educational debt  Perform 2 years of research --  concurrent with loan repayment period 2nd Yr Pediatric GI Fellows , 2012

LRP – Time-line for 2013 cycle  Sept. 1 – November 15, 2012 – applications accepted  Feb - April, 2013 – applications reviewed by ICs and funding plan prepared  May – July, 2013 – LRP office verifies financial information  July, 2013 – contracts issued THEREFORE – be very clear how you will be supported for the period July 2013 through Aug. 2015 2nd Yr Pediatric GI Fellows , 2012 Finally… the NIH budget is BIG…. 2nd Yr Pediatric GI Fellows , 2012 National Institutes of Health (’11) >$30,000,000,000 2nd Yr Pediatric GI Fellows , 2012