Teaching and Practicing Hepatology

Session 221

Dr. Richard Sterling has been an academic Gastroenterology and Transplant Hepatology physician for 26 years now. Let’s talk about his journey. If this is a field you might be interested in, check out The American Society of Transplantation and the American Association for the Study of Liver Diseases.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:17] Interest in Gastroenterology and Transplant Hepatology

Richard first became interested in liver disease when he was an undergraduate where he was a Chemistry major. He found all the biochem pathways fascinating about how the body builds things and breaks things down. He then furthered that interest with his master’s degree in biochemistry at the University of Texas -Austin.

Also, the chairman of medicine in his medical school at Thomas Jefferson University was a well-known hepatologist. And having worked with him, Richard ended up matching into an internal medicine residency program that had a strong hepatology program at Virginia Commonwealth University. Then he was asked to come back on staff in 1997 and has been here ever since.

[03:14] Traits That Lead to Becoming a Good Hepatologist

Richard points out that you have to have a good understanding of the way the body works and when it doesn’t work. He explains that one thing about hepatology and particularly transplant hepatology is when the liver goes bad, often the rest of the body follows.

And so, we have to have an appreciation of all the other organs that can go wrong and someone who has a really sick liver and needs a liver transplant. That includes the kidneys, the heart, and the lungs. You also have to take into account the immune system and bone marrow, the GI tract, the pancreas, and everything else that tends to go wrong when a liver patient gets sick.

Richard compares it to a multi-dimensional Venn diagram but you can’t tell what circles are overlapping what other circles because there are a lot of other circles in the way.

'When the liver goes bad, often the rest of the body follows... so we have to have an appreciation of all the other organs that can go wrong.'Click To Tweet

Now, they already have treatments for hepatitis C that can cure almost everybody. And when it comes to liver transplants, it’s so rewarding to see a patient who comes in near death and would not have survived without a transplant.

[05:29] Types of Patients

Most of his academic career now is dealing with liver disease in people who are living with HIV, which makes up most of his research. Richard also does a fair amount of transplant-related hepatology, but his practice includes patients with viral hepatitis, both Hepatitis B and C, and patients with fatty liver.

He gets several referrals for patients who also are living with HIV, which complicates the overall picture of what to do with those patients. He adds that most of it have to do with the risks of how they got HIV. Because of shared routes of transmission, Hepatitis C is very common in those with HIV. When he got done with his training, as HIV therapies got better, those patients were now living longer. And as a result, they were getting other liver diseases, then again, because of the shared routes of transmission, Hepatitis C was the big one.

Moreover, Richard would also see patients with both pre and post-liver transplants, as well as patients with hepatocellular carcinoma.

All that being said, he stresses how Transplant Hepatology is a team sport. They have to deal with surgeons, radiologists, and oncologists among many other medical specialties.

When he got done with his training and as HIV therapies got better, those patients were now living longer. As a result, they were getting other liver diseases, then again, because of the shared routes of transmission, Hepatitis C was the big one.

Back in the day, infectious disease specialists asked for his help in managing their patients. A lot of doctors didn’t want to deal with HIV just because there were a lot of unknowns. And this is actually how Richard got started in that field and then it evolved to HIV and hepatitis B. Now, his research has gotten into the fatty liver and those living with HIV.

[08:41] Typical Day

Some days Richard would have clinics, sometimes they were research-related clinics. He has a fair amount of research support, including NIH support. Other days are private clinics where he might see patients primarily pre-transplant. Their group has nine hepatologists and they sort of divide and conquer. He used to see a fair amount of post-liver transplant patients. But now, he has allowed some of the other partners who want to focus on those.

Sometimes, he would also have administrative work because he wears a lot of administrative hats within their health system.

Sometimes, he will have patients who come with unknown causes. When people see abnormal liver enzymes, usually, their first question is, who to refer to. Because they really don’t want to go through the process to think about it. So often, patients come to Richard as a mystery without really knowing what the problem is, or how bad it is. And so often, he would have to figure that out.

[11:08] Taking Calls

Their calls depend on whether he is doing the inpatient service where they have a dedicated house staff team. They would have a senior resident and two or three interns and a fellow. Oftentimes, he will get calls from them at night, whether there’s a problem with the patients or if they want to discuss a patient that’s newly admitted.

Back in the days when he had to take endoscopy calls, he would barely sleep due to cases that come in the middle of the night. But he’s not at a point of his career where he doesn’t have to take that kind of night call anymore.

Being in an academic setting also gives him some buffer since they have a lot of trainees who deal with the calls.

[13:15] Life Outside of the Hospital

Richard admits he had given up a lot of stuff to get to where he is. He had missed a lot of events, birthdays, anniversaries, family events, etc. Spending time with family has been challenging but he did what he could to spend as much time. Fortunately, he has been married for 30 years now and his wife has been very supportive of his career, letting him put his patients first.

At some point, something’s got to give. Richard has known a lot of people that trained with him who struggled and some people have had marriages that didn’t do so well. In any academic practice, you just have to try to decide what that right balance should be.

[15:57] Academic vs. Community Setting

Richard recalls how his college professor told him about the three kinds of people in this world: those that do, those who watch, and those who wonder. And early on he made the decision to become a doer.

He wanted to be an expert in something and become the type of doctor that other doctors would send their patients to, or their family members to. He also likes to teach so he knew he wanted that kind of aspect as well.

Richard adds that an academic career is a marathon, not a sprint. So he had to pace himself out. Hepatology was traditionally not a procedural-driven subspecialty so hepatologists made a lot less than gastroenterologists, even because they did fewer procedures. But as time went on, people have gotten a lot more appreciation about what they do.

'People have learned to appreciate the importance of meeting a hepatologist because there's really no one else who wants to deal with that organ.'Click To Tweet

[19:59] The Training Path

Richard says he took the long road after college. The medical school he got into right after college wasn’t his top choice and he thought he could do much better. And so, he decided to take a pause and do a reality check.

He then thought about a career in biochemistry that’s why he decided to take a master’s in biochemistry. But while he was there, he realized he really wanted to become a physician. So he applied the second time and got into almost every school he applied to.

After the internship, he then did a three-year residency followed by a three-year fellowship. Richard was interested in having a clinical research career. He didn’t like the lab so he got a second master’s degree in clinical research and biostatistics.

Richard’s extensive background in academics brought him a lot of opportunities and success. He became an Associate Program Director, in charge of scholarship and research. He has also been a program director for GI and for Transplant Hepatology. He also serves as the assistant chair for research for the Department of Medicine.

[23:20] Message to Primary Care Physicians

Richard developed the FIB-4, which is a simple non-invasive index to assess liver disease severity and it’s one of the most widely used indices around.

As a primary care doctor, Richard points out that you have to recognize that your patient might have liver disease.

And so, you should be screening for hepatitis C in patients aged 18 to 79. You should be thinking about fatty liver disease, particularly in patients who have obesity, hypertension, and diabetes.

A lot of electronic health records already have this built-in and this would help a primary care person to recognize that the patient might have a liver problem. Then refer the patient to your appropriate specialist.

[25:57] Message to His Younger Self

Richard says he would have probably told his younger self that if he really wanted a career in academics, it’s really hard. It has a lot of challenges, and you’re going to get a lot of disappointments. But if you want to succeed, don’t give up.

'The only person who never gets a grant is someone who never submits one.'Click To Tweet

Richard admits he has files of rejections and denials, but he has always stuck with things. You just have to be patient and learn how to handle disappointments.

Be flexible, and ask yourself, why didn’t it work and what you need to do to make things work.

[27:26] Most and Least Liked Things

'Sometimes you can't help everybody, but you can do the best that you can.'Click To Tweet

Richard says he likes being the doctor’s doctor. He has a lot of faculty staff who either come to him or send their family members to him. And he feels honored to be able to provide care. He also likes teaching and providing the next generation with his version of how to approach things.

On the flip side, what he likes the least is mostly self-imposed as he ends up overburdening himself and things could get overwhelming.

[32:01] Major Changes Coming to the Field of Hepatology

Richard is proud to say that in his academic lifetime, they have gone from discovery to cure of Hepatitis C. It has been a wonderful journey that he has been able to be a part of and that he has made some contributions too.

Additionally, there are a lot of exciting things happening with the Hepatitis B virus, which is a DNA virus. They’re looking at combinations of treatments that are hopefully much better than what they currently are doing.

Fatty liver is the big disease they are dealing with right now with a ton of clinical trials being done out there and his center is very involved in those.

Alcohol is another big problem. Now, it’s even gotten bigger during the pandemic, as people are now staying home and drinking. They have now changed how they have approached alcoholic hepatitis, including now doing liver transplants on select patients who come in with alcoholic hepatitis.

'Now, we have treatments for liver cancer where patients are living much, much longer with better qualities of life than they ever have.'Click To Tweet

[35:31] Final Words of Wisdom

If he had to do it all over again, Richard says he says there isn’t anything else that he’d be doing.

Finally, his message to students out there who might be interested in Hepatology is that Hepatology is a wonderful field because you get to have a little bit of everything. And if you decide to focus on one of those aspects, you have the ability to do that. There are not a lot of other specialties out there that give you such a variety of options to focus on in your career once you get there.