Welcome, everyone, to today's ADA Scholars Program. We're really excited that all of you are here. My name is Brittany Bruggemann. I'm an assistant professor of pediatric endocrinology at the University of Florida. So thankfully, we only had to drive a couple hours to get here. It was nice. I, just a little bit about my background, I'm about to start my fourth year as faculty. So I was not in your shoes all that long ago. And I came to ADA Scholars, which was focused on fellows in the past, and really got a lot out of it. And so I decided to join the group that helps to plan this and kind of give back a little, because I really did get a lot out of it. So I hope you'll also get a lot out of it today and tomorrow. I do mostly research now. So I do type 1 diabetes research, mostly into the exocrine pancreas. So now I'm sort of a hybrid gastroenterologist endocrinologist. And I also do some health equity research as well. So if you want to come talk to me at any point in the conference about doing research, getting NIH grants, or foundational grants, those sorts of things, I'm an open book. Or having kids, all those things. Let's see. So like I said, I am part of the ADA Early Career Advisory Group. And none of this would be possible without their planning. So we wanted to thank the rest of the group. We're also very grateful for the support of the Leona M. And Harry B. Helmsley Charitable Trust, who've made this program and in-person meeting a possibility. And we have a few things to go over before we start. So as an ADA Scholars participant, you receive complimentary registration to scientific sessions, which is excellent. And we hope you get to enjoy as many sessions as possible. Make sure you go over the planner. The app is really helpful. I've already planned out everything I want to go to, because I was really excited. And of course, there's like two talks at once that I want to attend throughout the whole meeting. So I have to still figure out which one. But it's a good starting place. This is another great benefit for you all. You get to visit the ADA Scholars lounge throughout your scientific sessions experience. This is advancing on its own. Sorry. There we go. For complimentary lunch, beverage, snacks. And that is a big deal, because if you see later in the scientific sessions, the lunch lines can get a bit long. So you don't have to wait in the line to get free lunch. Go relax. Go network. You'll hear about networking later. But that's an important part of your scientific sessions. So definitely do that. So Saturday and Sunday, 1130 to 130. Make sure you have your ribbon on your badge, because that's how you get in to the lunch area. Other benefits that you get. You get a free ADA professional membership as part of this program, which is also very exciting. So you'll get meeting discounts, part of the WinADA, which is a great networking opportunity, interest groups. There's a lot of different journals. So make sure you investigate all the different benefits to your membership. So for today, we have a really exciting program. This is the agenda that we're going to follow. Today's presentations and workshops will have questions and answers throughout. So please ask your questions. There's a mic there, and there's a mic over there. So make sure we want you guys to definitely ask the presenters questions. And a lot of the presenters today are repeat, and they are excited to talk to trainees and fellows and early career people. So don't be shy. OK, so for our first session, very exciting. We're going to take a deep dive into diabetes technology with Dr. Earl Hirsch, who is a repeat offender of this program and is one of those great people who is a super expert in the field, but also loves to speak to trainees and teach you guys. So please ask your questions. Dr. Hirsch has focused on studying the best strategies for the use of insulin therapy in type 1 and type 2 diabetes. He's a passionate advocate for patients, ensuring access and affordability for glucose monitoring, and in the past decade, insulin, authored more than 300 research papers, more than 60 editorials, including in the New England Journal and JAMA, and numerous book chapters, in addition to six books for patients and physicians. And he's a longtime volunteer for the ADA and has been on many boards and committees within the ADA. Welcome, Dr. Hirsch. Thank you so much. Thank you. This is great. I never get to start early, because this is a lot to do in an hour. Well, first of all, thank you for the introduction. It's great to see everybody. And I always like to start by knowing who my audience is. Raise your hand if you're finishing your first year in fellowship now. A few of you. Raise your hand if you're finishing your second year. More especially. OK, this is the experience table right in front of me. What about third year or beyond? A few of you there. OK. Well, it's great to be here. It's true. It's been a few years since I was in your spot, like 35. I mean, the time goes quick, as Dr. Eccle knows. It goes very quickly. And I'm just really honored to be here. And I've been involved in many different clinical trials, both with type 1 and type 2, mostly type 1 diabetes over the years. And just a little bit of self-promotion for the two major randomized controlled trials multicenter at this meeting. On Saturday morning, we will be presenting the results of the INHALE-3 study, looking at pulmonary inhaled insulin with insulin deglidec, which is Treceba, versus usual care. That will be on Monday at 8 o'clock. Let me go back. That's Saturday at 8 o'clock. Then Monday at 315, at the very end, we are presenting the data from the TITE trial, which is the use of inpatient CGM to improve glucose control in the hospital. And I can't tell you the results of that, but I can tell you it's very interesting. And I hope as many of you as possible can come to that. And then the final thing, if you're interested, I can just ask me, and I'll be happy to get you the information. It's not on the program. I'm involved in a debate Monday morning at 8 o'clock. Should we be using hemoglobin A1C, or should we be using the GMI from the CGMs? And that debate is on Monday at 8 o'clock. It's sort of a secret society kind of thing, but everybody's welcome. And if you email me or ask me, I'd be happy to tell you where it is. So with that, we're going to move in to diabetes technology and how you do this. And I kind of feel like this is worth a day or two days, because there is so much to talk about. The issue now is, if we look at type 1 diabetes, nationally, we are now over 40% of patients are on insulin pump therapy, most of this automated insulin delivery. There have been some surveys, one last year, that showed that not everybody was on automated insulin delivery system, hybrid closed loops. But I really question that survey. In our clinic, we are just a little bit under 80% of our type 1s are on pumps, and almost all of them are hybrid closed loop. Almost all of them. And what the problem is, is they all have their own quirks. The things that you do to tweak them to get the best glucose control is different. And unless you are either doing the clinical trials, or you have a lot of these patients on each of these different systems, it becomes really difficult to really understand how to get the best out of each one. And I think the good news is, is these are becoming so popular that most people who go into practice, or even if you're in an academic setting, there's going to be more of a demand of this technology, which is a great thing. But if you only have one or two patients on any given system, it's really hard to learn it. And so what we're going to do today is talk a little bit in general about these different systems. And then we're going to go through some cases. And we're going to try to figure out what's the best thing to do for that particular patient. Now, this is a website from it's pantherprogram.org from the Barbara Davis Center in Denver. Anybody here from Denver, University of Colorado? Yep. Yep. Dr. Echol and somebody over here on my left. Well, I want all of our fellows at the University of Washington in Seattle to know this, because this has been pretty much updated over time. And I'm not going to go through all of this in detail, but just note that there are four different systems. The Islet, the beta bionics pump, the MiniMed 780G, the T-SLIM, ControlIQ, and the Omnipot5. And what needs to be noted is that they're all a little bit different the way they do things. There's basal automation. There's bolus automation. And note that, just as an example, with bolus automation with the Islet, all meal boluses and correction doses are automatic. In other words, there's nothing to do except you give the bolus as usual low or high. And that's all you do for that one. Whereas with the other ones, you generally put in the amount of carb. But as far as automated boluses, there are no automated boluses, for example, with the Omnipot5. It does everything by automating the basal if the blood sugars are higher. And you need to know that. Whereas with the 780G, which is really interesting and we will see, you get a little automated bolus every five minutes. Whereas with the Tandem, ControlIQ, you will get it every hour. And it does a calculation, so it will give you 60% of the anticipated bolus that you will need every hour. But I think the more important point is not all of these details, but knowing that the algorithms and how they work are very different for each of these systems. And it gets really complicated. Can users adjust the basal rate? Well, this one is actually pretty important. The only one you can is with the ControlIQ, because the Tandem ControlIQ uses that basal for calculating how much of the automated basal it should give. The other three, there's nothing to do with the basal unless you go on manual mode. And then it will revert to the basal. But I always ask a fellow when they come in and they present a case. And I say, well, what do you want to do with the basal rate? Or what do you want to do overnight with that basal? And they'll give me an answer. But if it's anything but ControlIQ, there's nothing to do, because the basal is all automated. So that's really important. Can users adjust the correction factor? That is the sensitivity factor. And for ControlIQ and Omnipod 5, it's yes. But the correction factor does nothing for ControlIQ for the algorithm, especially for the boluses and giving extra insulin. And these are little things that individually, they're not that important. But as a whole, it's very important. What about the correction target? Turns out the correction target is very important for each pump and where you get the best glucose levels. And there's actually data for all of this. And this is very important, the extended boluses. And in fact, we use this a lot in our type 1 patients who are using GLP-1 receptor agonist off-label. It's very helpful in that situation. So that's important. The other thing about the ControlIQ is this sleep mode, which we use. And we'll talk about this in one of the cases. Because what's important about sleep mode is it does bring the glucose target down to 112.5. Well, there is a trivial pursuit question. It does bring it down. But it doesn't give automated boluses. And not getting automated boluses is actually really important at certain times, whether it's overnight or other times of day. And then which pump settings can be adjusted to change meal and our correction bolus doses? That is, insulin delivered by the user. And so this is just sort of summarizing for each one of these. And I'm not going to go through them. They're all on the website. But what are the levers that every clinician and patient can change to get the best out of the pump? And note that there's really nothing to do here. And this isn't quite true with the islet. And we're going to talk a little bit about the islet. But you can't change an insulin to carb ratio. You can't change its sensitivity factor. You can't change the insulin action time like you can with the Medtronic. There's really very little to do with the islet, although there is a lot of education. And the final thing is I want to point out that there is a way to get a limited automation on these pumps. Even in the islet, you can get something they call BG run mode, where you don't have a sensor for whatever reason. Maybe you're just warming up. And if it's a longer period of time, you can put glucose levels into the pump. I mean, and these are things that you really need to know when the patients call and they're kind of freaking out. They have something called safe basal mode for the 780G. There is no limited automation for control IQ. There is just you can turn control IQ off. Or it just automatically goes off if there's no sensor data. And then there is a limited automated mode for Omnipod 5. But the point is they are all a little different the way they do this. Now, I have my opinions about which pump would do better in a clinical trial. But my opinions really don't matter because nobody is doing trials head to head on these. But I'll tell you what I do do. What I do do is I personalize which pump I recommend for which patient because they're all different. And one of the good things about doing this, as long as I have with many of these patients over 30 years, I know their personalities. I know when they're missing their boluses. I know when they're late with their boluses. I know who the exercisers are. I know all these things about these patients. And many of these patients have been on their pumps for a long time. And because of that, knowing these pumps the way I do, I can usually try to put the right pump on the right patient. With that being said, there are some patients who want to be on a certain pump no matter what. The biggest example of that is the Omnipod 5 because a lot of patients don't want any tubes. I get that. And that's fine if that's what they feel is best. So we're going to start with an Omnipod 5 patient. And there's nothing really, I just want to show you how I think through this and how I walk through this. This is a 44-year-old woman. She's had her diabetes since she was 15. And she had a very interesting pattern with her blood sugars in that she would have these massive spikes late night and early morning, even when she didn't eat dinner. It was like she had her dawn phenomenon, but it really wasn't dawn. And we were able to change her carb ratios and her basal rates and so forth over the years. But then she went to Omnipod 5. And she has done very well. And the way I look at this is the first thing I look at is the time and range, which is 88%, which is great. Her time below range is only 1%, which is great. I look at her GMI, which is what our debate is going to be about. It's her estimated A1c, for those of you who are not familiar with that, 6.6%. And just out of curiosity, and I'm asking this to try to learn a little bit about you, raise your hand if you did not know what GMI was or how it came. You're all familiar with that term? I just want to make sure, because if you're not, we should stop and talk about it a little bit. I want you to note that she's on 50% basal and 50% bolus. And although that's what we have been taught, that that is the appropriate ratio of basal to bolus insulin, as it turns out, that's probably not exactly right for most patients if they are eating an isocaloric diet. What we see in patients who are doing well, and this patient is doing well, more often than not is only 40% to 45% basal. It's more bolus than basal, at least in adults. And that's just been my experience. I don't have enough experience in the pediatric population. But that's what we see over and over and over again. And I just want to show you something here. I want you to look at her carb ratios. It's a 9 at midnight, 7 at 11 AM, and 6 at 3 PM. I know it's small. But I also want you to note her sensitivity factor is 50. And my question to you is, does that seem appropriate? You're shaking your head. Why do you say no? I agree with you. I think what I've been taught with 1800 rule or the 450 rule, it would approximately be either 4 times or 5 times the insulin carb ratio. Right. So you're right. The carb ratio seems too aggressive for the sensitivity factor. And so this is a mismatch. And I look at this in pretty much every patient. As a rule of thumb, a sensitivity factor of 50, and I don't do the 1800 rule at all anymore, because I've been doing this so long, 50 should be a carb ratio of about 1 to 15. An insulin to carb ratio of 12 should be a sensitivity factor of 40, maybe 35. If you get down to 1 to 10, it's usually between 30 and 40. But this doesn't make any sense. And so if I see a problem with her, if her time and range is off, if she's having too much post-meal hypoglycemia with this carb ratio, I would make a change. But she has 88% time and range. And I'll tell you what I actually think is probably happening with her. I think she's miscounting her carbs. And I think the sensitivity factor is right. But she's consistent. There's no sense, and I learned a long time ago, you don't need to send these patients to the nutritionist. She's been doing this for decades, and it's working. And it's working well with this sensitivity factor of 50, the way she's counting carbs. So I just leave it alone. She's doing great. And I wish we could say that about everybody, but we can't. Here's one. It's a 58-year-old woman, type 1 diabetes since 18 years of age. She has CKD. She has albuminuria. She has stable proliferative retinopathy. She did not do well on her 770G. She wants to try the Omnipide 5 and look at her A1C. Her A1Cs are between 7 and 1 half and 8 and 1 half. And let's take a look at what we see here. As opposed to our last patient, she has a time in range of 54%. She has 0% time below range. She has a GMI of 7.7. She has a coefficient of variation of almost 35%. Now, we're going to talk about coefficient of variation in a moment. So we'll just put that on hold. But you look at the ambulatory glucose profile. What do you think? This is the ambulatory glucose profile. When you see this, what are you thinking? She's not bolusine 432? Say that again? Maybe not bolusine 432. Maybe not bolusine for her meals. You guys are good. Look at this. She has 68% basal and 32% bolus. And when I see that, what I'm thinking is she's either eating a low carb diet, very low carb, or she's missing her bolus. And if you look, she's only entering her boluses 2.6 times per day and a 46.6 gram per day total carbs. I mean, we're getting into keto territory here. And she is not eating a keto diet. And when I see these spikes, I say, you know what? I don't think she's bolusine. And we can look, and we can see exactly that's what's happening. The pump brings her down overnight. She wakes up with a great blood sugar. But she's obviously eating here. The red on this pump means that the pump is suspended, whereas these orange or yellow that you see down at the bottom, that means it's giving her maximum basal insulin. Remember, this pump automates basal, but it does not do any automated boluses. But look what happened. Her blood sugar went very high. It went up here and tickled 300. And when it tickled 300 is when she took her bolus. Blood sugars then came down with the basils. It came down. She gave a 10 gram bolus here. And again, she went back over this time over 350. She's just not paying much attention here. She's not paying much attention. And you know, one of the things that we typically do for somebody like this is we will pay a lot of attention to the alarms on their sensor. But a lot of times they don't hear the alarms because they're going off so much. They get alarm fatigue. And there's an entire science on what's the right alarm. Because as a rule of thumb, the philosophy, at least my philosophy, is if the alarm goes off, whether it's a low alarm or a high alarm, you need to do something. So if someone like this with an average glucose of 184, if you have the alarm at 180 or even 200, that makes no sense because the alarm is always going off. You need to make the alarm high enough so if that alarm goes off, they're going to bolus. And they need to know that that's what they need to do. But I think the real big teaching point here is that not everyone does well with AID. And the one thing we've learned is that some people do better with one type of algorithm compared to another. And I'll just say flat out, if this patient wanted to change to a different pump, I think she would do better on the beta bionics islet because there is so little the patient has to do compared to doing well on the Omnipod 5. That's an opinion. I hope there's nobody here from Kelly Close. I don't want to be quoted on that. But that's sort of what I think. Now, I want to show you some things that I did. We did a couple of papers. Actually, there's another one that will be coming out. I did with a resident who then became a fellow at Hopkins and she's now on faculty at Hopkins. Is anybody here from Johns Hopkins? No. Her name is Jordan Pearlman. When she was a resident, we went through over 600 patients from our clinic and we looked at the discordance between A1C and GMI. But what we did in a subsequent paper is we looked at coefficient of variation. And the reason why coefficient of variation is so important is that the ADA actually has a target for coefficient of variation. Does anybody know what that is? 36. And I never understood that. And I said, you know what? When you're 36, you're missing boluses. You're having hypoglycemia. I said, in my wisdom, I thought it should be 33. And of course now, with AID, every day I see patients below 30, which is great. But why 36? So we went back and we looked at these people and we looked at there's actually, I believe, over 600 individuals here. And we did this both with A1C and GMI. I'm just showing you the GMI. Well, let's go to 36. Is my pointer showing up here? You know what? I've been using this pointer and the pointer is not on here, is it? Oh my. I apologize. I thought the pointer worked. And this pointer doesn't work either. Okay. I'll do this without the pointer. On the X-axis, you can see the 36 at the bottom, right after 35. If you look at the blue line and the brown line, you can see that the hypoglycemia time below range at 36 is almost zero in our population. Yet if you go up to the green line at 36, you have at 36 a time below range of about 4.5%. And at 36, if you have a GMI of 6, which is the red, you have a time below range of about 8 or 9%. The point being, the coefficient of variation can't be looked at in a vacuum. The coefficient of variation is very much dependent on what the mean blood glucose is. And as you can see, if you get down to a coefficient of variation of 30, you can still have about 3% hypoglycemia with a GMI of 6%. So just having a single number as a target for coefficient of variation, you can't do that. And I still look at it, but I try not to emphasize it with patients because it's a complicated topic. Let's look at this next case. It's a 59-year-old woman. She was diagnosed with OCD and type 2 diabetes when she was 51 years of age. She was frustrated about her poor glucose control despite low-carb diet, metformin, sitagliptin. She was taking bedtime Glargine. Her A1c was 8.6. Her BMI is 24. She has hypertension and she has hypercholesterolemia. And I will also mention she is African American. And she self-referred to our clinic in Seattle. And here's her Dexcom. And what you see is that she has a mean glucose of 195. Her time and range is 39. And look at her coefficient of variation. It's under 25%. So she comes in the clinic. I'm seeing her with a fellow. What do you want to do? A, measure autoantibodies. B, measure her C-peptide. Or C, measure fructosamine. How many like A? How many like B? How many like C? This is so. 25 years ago in our clinic, about once a week, we had somebody come in with type 1 diabetes who was misdiagnosed with type 2. Today that number is every single day there is a new patient coming in who's misdiagnosed. Every day. Part of it is because we're seeing more type 1 diabetes. And part of it is our clinic is much larger now. But the point is she has a low BMI and she's making insulin. And the fact that she's making insulin is the reason why she has such a low coefficient of variation. She's making quite a bit of her C-peptide. Now, measuring C-peptide isn't going to tell you if she's type 1 or type 2. She's making insulin. She has adult-onset type 1 diabetes. She has RADA, latent autoimmune diabetes of adults. She is making insulin. And when we measured her antibodies, two of them were positive, the GAD65 and the IA2. So I started her on basal bolus. We used an in-pen. How many of you are familiar with the in-pen? Smart insulin pen. Most of you are. It's fabulous. It's not as much promoted or used outside of our clinic as I wish it was because I can see how the patients are thinking. I can really see that. And I want you to look at this. Now, she was not hooked up to the sensor yet, but she didn't need to be hooked up to the sensor with the sensor hooked up to the in-pen download. And the reason is she's putting in all these glucose levels because she has OCD, which is a good thing right now. Okay. And what I want you to notice down here is you see all these check marks. Whoops. I'm sorry. I'm using the pointer and you can't see it. You see the check marks? Those are the check marks of the boluses. That means she is doing what the pump is recommending. She is doing what the pump is recommending for her to do. So you can see when her blood sugar was 270. And again, I really apologize that the pointer doesn't work. But at 270 on March 21st, you see 1.5 units. She did what the bolus calculator on the in-pen recommended. The blood sugar came down. She didn't take any more insulin until it was 182. She did what the bolus calculator told her to do. And what you can see is that her blood sugars are high all day. What you can also see is the eight units of basal insulin. I'm pretty sure it was glargine. You see on the far right in the blue circle, that's the glargine. And you can see that her blood sugars are pretty much high all day. And so I'm just going to go on. Now the in-pen, this is what we saw. Let me ask you the question. This is the in-pen on the app. This is what we saw. When you look at this, what do you think? Raise your hand if you're okay with duration of insulin action of four hours. Does that make sense? Are you okay with that? I'm okay with that. I'm fine with that. Raise your hand if you think the target of 150 is okay. Are you okay with that? No. I see people shaking their head. It's only doing the mathematical calculation to bring her down to a blood sugar of 150. So right away in this woman who's never had hypoglycemia, she's at a disadvantage. What about the sensitivity factor of 50 from 6 a.m. until 11 and then 70 the rest of the day? Are you okay with that? It's way too conservative. That's one of the reasons why when she took insulin when she's high, nothing is happening. It's because this is too conservative. What about the insulin to carb ratio of 60? What do you think of that? No. That's too conservative too. The moral of the story is don't let the fellow put the settings in without oversight from the attending because that's actually what happened. That's literally what happened. A check means that the dose was recommended. Now what you didn't see is you get these triangles up or down if they're overriding or underwriting. Again, this just comes from my experience. I like to see 15 to 20 percent on these MDI patients overriding or underwriting. The reason is the calculator doesn't know when the patient is about to have a tennis match. The calculator doesn't know if the patient is sick. The calculator doesn't know any of this information. There are times, and the most important one, if the trend on the sensor is going up or down. The calculator doesn't know that. I wish it did, but it doesn't for these MDI patients. So patients have to know when to override or underwrite, and she learned that. So let's fast forward to last year. Her OCD is better. She transitioned to control IQ, and here she is. She now has a GMI of 6.4 and an A1C of 6.9. With what I've told you, does that surprise you to have that discordance? Why not? You can expect the GMI to be within plus or minus one. And hers is 0.5 away. Does that concern anybody? So 0.5 differential, a discordance, actually is significant. But as it turns out from work that was done by my colleague Rich Bergenstahl and Roy Beck, African Americans, their GMIs run 0.4 to 0.5 percent higher. Their A1Cs, let me rephrase that, their A1Cs for any mean glucose runs 0.4 to 0.5 percent higher. And I mentioned she was African American. Now, that shouldn't matter, but it actually does because the A1Cs read higher for any given glucose. So this is exactly what you would expect. Exactly what you would expect. Now, let's look at this a little bit more. 94 percent in range. Excuse me. And she's below target. I'm going to take one of these water. One percent of the time. And look at this. Her control IQ autobolus is one percent. What do you think of this? When you're looking at this, I want to know what you're thinking. It's good? I'm sorry, say that again? She's asleep 20 hours a day? So in other words, she's a Colorado Buffalo fan. Sorry, it was just too easy. Well, yeah, we'll talk later. Listen. Actually, let me show you what she did. She's not sleeping, but she's in sleep mode. She did it by accident. And because she's still making insulin, the pump is modulating the basals, and she's doing great. Because if you notice, her food bolus is only 38 percent, and her basal is giving her 56 percent of her insulin. The modulating basal is taking care of the control IQ autobolus because she's still making insulin. Now, that was a year ago. I got to tell you, she's not making much of any insulin anymore. She has really pretty much lost all of her endogenous insulin. But it's just a point. She made a mistake, and she actually did fine with that lower basal, excuse me, with that lower target of 112.5. She did fine because she was, at the time, still making quite a bit of insulin. So she was on sleep mode the entire time. So in clinical practice and not in research, I do it at the time of the clinic visit because that's all I can usually do, and these patients come from so far away. With that being said, the most important thing about measuring C-peptide is you have to do it in conjunction with what the blood sugar is. Because if you have a blood sugar of 75, the C-peptide isn't going to be very helpful. But if the blood sugar is 175 or 225, the C-peptide is going to be helpful. Research-wise, we will do it fasting, and even more on the research side, we'll do it with a mixed meal tolerance test. Important question. But that's really important. Just measuring a C-peptide and not knowing the glucose at the same time is not helpful at all. You have to know the glucose. And in fact, if I'm going to do it and they're all wearing sensors and they have a glucose of 80, I have them rev it up. I have them eat something without a bolus to get the blood sugar up before I measure the C-peptide. She's making a lot of her own insulin. Let's look at this guy. How am I doing time-wise? I'm okay. It's a 54-year-old man, control IQ for a year. His time and range is usually in the high 70s, so this is another control IQ case. Father just moved in with him, home hospice with his son, a very, very difficult time. And you can see his time and range is about give or take 14% lower than usual, and his control IQ autobolus here is in double digits. I'm going to say something that's a little bit esoteric, but this is with the old download for control IQ called T-Connect. The new one calculates the autobolus differently. It calculates autobolus with just the percentage of mealtime insulin. This is looking at the percentage of all insulin, and so the numbers are different. It doesn't seem like it's important. It's actually very important. As it turns out, this is quite a bit of control IQ autobolus, so the blood sugar is high, and every hour it gives an autobolus. And take a look at this. What do you think? What do you want to do? And just for those of you who are not initiated, I'll try to talk you through this. You see the black squares with the white blood. Those are the autoboluses, and you can see it on both of those days. You see this, and you see those autoboluses, and you look at the patterns. Anybody? What would you want to do if this patient was in your clinic? I just did overnight insulin because he's waking up too high and getting a lot of autoboluses overnight. Okay, so let's think. So what was said was a lot of autoboluses overnight, and to say it again, adjust the basal. Okay, so let's take a look. If you can see at midnight, and actually at 10 o'clock, you see the three Zs. That means he's on sleep mode, and when he's on sleep mode, it's a lower target, but he's not getting autoboluses. He's maxed out with the basal. Maxed out with the basal pretty much both nights. Not as bad on the second night as the first night, but he's not getting autoboluses because that's the point when you are in sleep mode. You don't get autoboluses, and what he's doing is he's eating late at night, maybe not doing a great job with the boluses while he's taking care of his father. This is a very unusual, difficult, emotional time for this man, and what I did was I didn't change the basal doses because I know the basal doses are fine, but his situation is very different for a finite period of time. All I did was I turned off the sleep mode so he would get the autoboluses because he wasn't getting any. His diabetes isn't his priority, nor should it be his priority right now. His priority is his father, and I think that's sort of another huge point. We have to look at just not the diabetes, but everything else going on in their personal lives, and this is a big deal. Big deal. Okay. A type 1 patient diagnosed at the age of three. Father had type 2 diabetes. He died of a myocardial infarction in his 50s. Our patient had extreme insulin resistance. It's somewhat improved now. She had been on about a thousand units of insulin. I actually sent her to the NIH, and they couldn't figure her out probably 15 or 20 years ago, and she's a C-peptide negative type 1. She also now has primary biliary cirrhosis, stage 3 CKD, proliferative retinopathy. She has severe visual impairment from that. She had been on a Medtronic 670G, using it with a Dexcom. Has anybody seen people doing that? That was sort of like the most common thing when the 670G came out, unfortunately, because at the time Medtronic's sensor was not up to snuff with the Dexcom, and we had all these people using open loop Dexcom and Medtronic. We don't have that anymore, but that's what she was doing. Her time and range was never to target. Her GMI was usually around 9%, and she had multiple episodes of DKA because of her vision. Her brother has type 1 diabetes. He lives next door, but because of her vision and sight issues and kinks, and she wouldn't come off of her pump. It's a whole other discussion that we won't talk about now, and that's the skin issues and the skin challenges with pumps. She would not come off of her pump, and she would have to change her sights frequently anyway because of the fact that she was going through insulin so fast. But she was having this DKA, and I guess we tried each GLP1 on her. She didn't tolerate any of them, even at a low dose. What do you want to do for this lady? She comes to your clinic. What do you want to do? I even heard from people over here. I'm going to ask the left side of the room. What do you want to do for her? So right now, it's a great question. Right now in her pump, she's using Humalog, Insulinalyze Pro, U100, and her total daily dose now is a little under 200 units a day. So she's going through this quickly. And which infusion set? The extended wear infusion set, okay, and using U200 insulin, okay. Metronic has a large reservoir. What's the other pump with the large reservoir? Metronic and tandem. Yeah, and that's really important. You have to know this patient can't go on Omnipod or Betabionics, but her pump warranty is about out. So U200 insulin, off-label, but you're very familiar with it. As an endocrinologist, you want to know about off-label. Well, let me tell you what I did. The first thing I did because of the DKA, I gave her 10 units of Degladec in the morning, not enough to have a big impact on her blood sugars, but she's had no DKA since. So even in the situation where she's out of insulin and she doesn't know it or she has a kink or something, she has not had any DKA. So that was good. I put her on a 780G. Now you remember where her blood sugars were. 30 to 30 to 40 percent time and range, GMI of 9%. She's now 76% time and range. Note her carb ratios. Now she's on U200 insulin. I want you to see something. The amount of time she's on closed-loop is 87%. Her GMI is 7.1 from 9. Not bad. And she has a high coefficient of variation, but I have to tell you, and again I don't want to do advertisements, but we have been amazed in our clinic what we have seen with this new Medtronic pump. We have been amazed and I'll show you why in a moment. Now this is a little misleading. It says 94 units a day, but she's on U200 insulin. You got that right. So she's on a more concentrated insulin. She has a GMI of 7.1 and she says she's, she always tells me she's only eating once to twice a day. And we can actually go in here and take a look exactly what she's doing. You see the blue arrow over here? She's had that spike up. That was at about, what, 7 or 8 in the morning. She had some breakfast. She didn't bolus, and you'll see better on the next slide, but you see all those, you see the pink line? That's the basal, but below it you see these little blue dots. Can you all see those blue dots? Those little blue dots are the every five minute automated boluses, and what you see is without any bolus at all, by 3 o'clock in the, actually by noon, her blood sugars were back in target, even though she didn't bolus. That, to me, is amazing. And what I see here is that she's not always bolusing. What I see here, right here, you see a lot of those automated boluses and a very high basal. I don't know if she had a snack there or what the reason is, but she, for the most part, stayed in range that entire time. And the same thing happened there. I'm not a hundred percent sure she ate. I'm sure she did, but she did not have a, she did not have a bolus with that. And if you see on Tuesday, March 5th, she had a bolus of 16.5 units at 11 o'clock in the morning. She had no spike at all. None. And I wanted to show you something I teach my fellows. Where that arrow is, I didn't mention that, and you see how the blood sugar goes straight up there? So the rule of thumb is, if it goes up more than 45 degrees, guaranteed they ate without insulin. Guaranteed. It's called the 45 rule, and it was not named after the 45th president. Okay, here's another tough one. He has type 1 diabetes, but he also has cystic fibrosis, exocrine pancreas. He's 37 years old. Very, very difficult history. When he was transferred to me from Seattle Children's Hospital 15 years ago, I diagnosed him with diabetes insipidus. I put him on U500 insulin because I couldn't control his blood sugars. He was eventually diagnosed with CNS nocardia. His diabetes insipidus went away. He came back onto U100 insulin, but there was a metabolic memory to that, and that was the entire family completely scared to death, fearful of hypoglycemia. He had two hypoglycemic seizures on the U500 insulin. He now has end-stage liver disease, end-stage kidney disease. He's starting peritoneal dialysis, but I get a call from the nephrologist. They will not put him on the PD unless his blood sugars are better controlled than they are now. Right now, he's getting about 90 units of insulin with MDI, Degladec, and Lyspro AABC. What's Lyspro AABC? What's that? Lumjav. Okay, so he's on our best insulins. We're trying to do everything we can, and this is what he looks like. He has a GMI of nine and a half and a low coefficient of variation. What does that mean? Say that again? He's just high all the time. That's right. He's all high all the time, and this is what actually happened. What actually happened, if his blood sugars are coming down to 200 or even 180, either he will treat it or his mother will treat it. I tried psychological counseling. They refused everything because they did not want the blood sugars to go low. The entire family. I'm not just treating the patient. I'm treating the patient and the mother, and the father's just rolling his eyes because there's nothing dad can do. It's very frustrating, but now there's something else going on. What's going on now is he can't go on the peritoneal dialysis unless he's better controlled. I want you to note his time in range is 16%, one six. What did I do? I had a long talk to the family about the islet and not to protect against hypoglycemia with extra carbs because you can't get away with that with the islet because it will always give you insulin to get you down to the target. I also had to have a long educational talk with a nephrologist, which I did. Everybody was on board with the plan. I started the islet. 30 days later, I do a visit with him. He's now on the peritoneal dialysis and he's on the islet. His time and range was one six is now 65.2% time and range. His time below range is 1.2. His GMI is 7.3. Note he was on 90 units of insulin a day. Note that he's only getting a little under 33 a day on this. He was not on the inpen because he was on the lumgev, so I couldn't see what he was really doing with his insulin. Actually, over the next few months, he's actually done better. This is his secret. He gives the bolus. He's usually pretty good with giving the bolus. Then he doesn't look at it. That's the key. Just put the duct tape over it. Don't look at it. Let the pump do its thing. If you let this pump do its thing and you don't pay attention to it, you're going to do great. That's the point. You don't have to look at it. That's exactly what happened with him. It was a lot of education to get the mother and the doctor not to overlook at the pump and look at the sensor, but they did. Because of that, this is on peritoneal dialysis, by the way. He's done fantastic. I'm waiting for the shoe to drop, but so far it hasn't. That's the first case. Let's look at this one. 44 years old, history of eating disorders, severe depression, proliferative retinopathy, stage 3 CKD, polyneuropathy, fear of hypoglycemia. How many of you in the room are pediatricians? I didn't ask that. A lot. This is not a patient you will see. Bear with me here. A1C is usually double digits. Not a good sign. When you see a double digit A1C, what happens? They're not taking their insulin. You can't get a double digit A1C if they're in type 1 diabetes if they're taking their insulin all the time. She's missing insulin. She was on open loop for many years. She rarely bolused due to fear of hypo. Unplanned pregnancy six years ago. She did okay with her insulin, but she was on open loop for many years. She rarely bolused due to fear of hypo. Unplanned pregnancy six years ago. She did okay with her diabetes, not great then, and the baby turned out to be fine. The baby is now five years old. After a long discussion, she decided to move from open loop Medtronic to the Medtronic. So this is day one. What's the problem here? What's the problem? Anybody? There's a huge problem here. You know this is not going to end well. Does anybody see the problem? Did I tell you? You never start a pump at 4 o'clock on a Friday afternoon. Ever, ever, ever. And not only was the pump started by the pump trainer at 4 o'clock in the afternoon and our nurses didn't know, not only that, but her husband was out of town that weekend on business with a five year old. This is not going to end well. So you see what happens. The dinner bolus she put in normal and her blood sugar went up and then the pump brought it down. The way this pump works is that you put in your weight. It calculates a units per kilo when it starts and it learns. It learns over time how much you need when you're high, how much you need for a small breakfast versus a large lunch. It learns. So she started at 4 o'clock in the morning, like 4 o'clock in the afternoon. Her blood sugar went up to into the high 300s. It came down into target by midnight. Overnight she did fine. She gave a breakfast bolus and what you see is she then got hypoglycemic. She freaked out and she did what she was taught not to do. She over treated it. She went over 400. Don't know how much she ate, but she over treated it. Then what happened was she ate lunch with the blood sugar in the 400s and it figured it needs to give a lot of insulin for that. And this was her first severe hypoglycemia. She doesn't remember this. All because she over treated it. Then she woke up. She over treated it. Remember, there's a 5 year old there. She went back into the 400s and then she did something really, really dangerous. She gave her dinner bolus, you can see at about 7 o'clock. Less than 4 hours later, and less than 4 hours is important, she gave another bolus. As it turns out, she didn't really eat, but she saw that high blood sugar. The last thing you want to do on any pump, but especially this pump, is give insulin when you're not eating. We do fake carbs, we do fake boluses with the other pumps, we can usually get away with it. You can't do that on this pump. Remember, we're now Saturday night, 5 year old at home, husband's on the east coast, which is okay if she's on the east coast, but she's not. She's in Seattle. So, she gave this bolus without eating, and then what happened was, she saw her blood sugar going down, she saw it trending low, she didn't get low, but she ate, and she did not announce it. The pump then gave her more insulin there at about 2.30 in the morning, but it thinks that her overall insulin requirements are high, and there's her second severe hypo. She wakes up, she then goes way up into the 400s again, she gives her breakfast bolus, she then gives a lunch bolus, and what happened when she went up, the pump thinks she needs a lot of insulin, and when she went, because of the first hypoglycemia treatment, when the blood sugar then got low around 6 o'clock, which she tells me she remembers as the 5 year old feeding her Skittles. This is what happened. And so, you know, those first two and a half days, she needed 180 units of insulin, she's actually getting ready to go back on the pump, she's meeting with a psychologist once or twice a week, I'm not sure this is the best pump for her, but the pump will always defend the target glucose, and in this case it's 120. It will always defend it, based on whatever happened before. Is that scary? We see the best of things in our short time with the islet, and this obviously is very scary. Raise your hand if you have any experience with this pump, I'm just curious. Okay, this side of the room more. Yeah, hopefully you'll never see anything like this. Overtreating lows and using fake carbs, can't do it with this pump. Let's just talk a minute about the algorithm. Basal algorithm, 288 mini basal rates, it learns it throughout the day, and it can learn if unannounced snacks by adapting, it adapts to increase needs at that time of day. The correction algorithm is also learned over time, and can be more aggressive with unannounced food at that time of day. The meal announcement algorithm, it's usual more or less, it adapts, and it adapts independently from each other, so a large breakfast is going to be different than a large lunch, and it's suggested, it is suggested not to announce a meal if it's more than 30 minutes later, the pump will catch up. Other tips, high alarm, it requires immediate attention. Most of the time, it's because of an insulin delivery problem, or it can also be because of overtreating a low. The overtreating the low is what got our patient into problems. The low alarm, it requires immediate attention, and you don't need a lot of carb to treat hypoglycemia on any AID system, because it's not like you have this basal dose of Glargine or Degladec there. You only need most of the time 5 to 10 grams of carb. You don't need more than that. Our ladies, if she had 100 grams, it wouldn't have surprised me, and that's what got her into trouble. The adaption only occurs if it's at least four hours between meal announcements, and that's important, because when she gave that extra dinner bolus, it was not quite four hours, so it couldn't adapt. It couldn't learn, and the other thing about the way it learns, which is really brilliant, is that if it's at least four hours since the last meal announcement, and it can be no more than 80 milligrams per deciliter above the glucose target, and this is how this pump learns how to do it. It won't adapt if you're eating without bolusing. Our patient struggled because overtreating the lows, treating hypo in anticipation, because the hypo may not have actually happened. The pump was suspended at the time, and the fake carbs for hyperglycemia. This is a huge problem. We've sort of gotten away with it up until now. Can't do it with this particular pump. She had these lows, and especially on the first few days starting when the pump is trying to learn how much insulin you need, I mean, what we obviously are doing is we're starting over and resetting the pump. Overtreating the lows. It thinks you need more insulin for these highs, so I have a couple of conclusions, and if I have time, I have one other case I'm going to show you very quickly. Each pump is different. You need to understand the basics to best help patients. As a rule, the smarter the pump, the more micromanaging will make things worse. The islet is the smartest pump. You can't micromanage with that pump, and we have these patients who always want to tweak the dials. This pump is not the best. Remember when I said we are now at a point in type 1 diabetes where we can personalize which pump for which patient? This islet pump is not for everybody, but it's for a lot of our patients who are not doing well. Understanding the significance of low versus high basal versus bolus, low versus high coefficient of variation, low versus high autobolus, if there is an autobolus, and it's okay to be creative like U200 insulin, pulmonary inhaled insulin, which we'll be talking about Saturday morning at 8 o'clock, or giving a low dose of basal insulin to prevent a sight-impaired person from going into DKA. Now, this came to me a few weeks ago. I want to see what you think. This was an email that came to me. I wanted to ask about one of my patients with type 1. He was diagnosed at age 7 and is now 28. He bikes 3 to 4 hours at a time at least once a week. He is considering a 100 to 150-mile bike ride over a 10-hour period. He's on control IQ. For the 3 to 4 hours, he has more carbs, so he can be in the 100 to 200 range before starting exercise, and he uses the activity mode on the control IQ pump. Despite this, during the rides, he needs to have 30 grams of carb every hour. When he was in his early 20s, he only needed 30 grams of carb for the entire ride. He's not sure what to do for a 10-hour ride since he'd prefer not to pack 300 grams of carb with him. What do you want to do? What do you want to do? He's on control IQ, so you can make a separate profile. Make a separate profile. Okay, what would you do with that separate profile? Half the amount of insulin. Half the amount of basal? Mm-hmm. What would you do with that? I would double the correction factor. So if he's at a correction factor of 10, you'd put it to 20. Okay, that's one option. I will tell you, we've tried that. It doesn't work. We tried that the first week we got control IQ. Any other ideas? It's a good answer, but it doesn't work. I'll tell you what we do. We put them on sleep mode. Why sleep mode? Because they don't get the autoboluses. The thing that hurts these people on the exercise, it's the autoboluses. They ram their blood sugars up, and that's fine. What happens is the autoboluses crash them, even though the target's at 150. Now, what we also do is we go down on the basal also, so it's harder to get hypoglycemic. We do do that, but it's the autoboluses on the control IQ that's the problem. Get rid of the autoboluses, and most of the time these patients do great. Okay, any questions? That was a lot of stuff to pack in actually in less than an hour. Yes, sir? Do you manage pregnancy? Do I manage pregnancy? I personally don't, but our MFM physicians do. It's somewhat controversial. Do you do it at your institution? Yeah, I think everybody does it, but what we need, and I have my five-minute warning, but what we need is we need more data on doing this. In the community, they're not. At many of the academic centers, we are. Where are you at? Dallas, Texas. Okay, anybody else? There's a lot of stuff to talk about, and you know what the shame of this is? I just skim the surface. I have a question. Yes? In your last case, if you're putting the patient on sleep mode, it's pulling your target lower. That's right. I know you're not getting them auto-corrections, but how are you preventing them from going low for this 10-hour migraine? The target is sort of not all that relevant when, you know, even if you have a target of 150 on activity mode, these patients are down in the 50s and 60s, and the pump is turned off, but it doesn't make a difference. Not to mention the fact, you're right, the target is 112, 112.5 compared to 120. I'm going to be showing data that's embargoed, but I can tell you this. I'm going to be showing data of AID pumps in the inhale three. These were the control patients. Half the patients were put on the Afreza and the Degladec. The other half were usual care, and half of those in usual care were on AID systems, most of them on control IQ. They didn't get close to 112. They didn't get close to 120 on AID. Not close. So I always think of that when, I don't know if I just broke the embargo, but it had nothing to do with the study results. Yes? Do you run into the same issue on Omnipod with your patients? I know it doesn't count. Yeah, Omnipod is different because it doesn't have the autoboluses. So in Omnipod, since it doesn't have the autoboluses, it's still an issue, and we'll still go down on the basal. But since it doesn't have the autoboluses, we don't have the same problems. It's those autoboluses that get us into trouble. So you said like a temporary basal? Temporary basal. Way, way down. And for some of these patients, at least for a short period of time, we'll even stop, suspend the pump completely. But never more than an hour, and usually I don't like suspending it more than 30 minutes. No? Yeah, oh, sure. attention to their diabetes? Why do you suggest, I mean, do you use the islet for this type of patient? Like teenage, I'm thinking of it in my head, a teenager who, you know, really doesn't know this for food, and that if they notice they're low, they might, you know, just take a handful of whatever's close to them. You know, they're not gonna think, oh, I need to limit it to 10 grams of carbs for, you know, a low correction. Or, you know, they might not notice if their pump stopped working for a little while. Yeah. What would you do for that patient? It's hard. I mean, the big thing in a patient like that is safety and to make sure that if they're not getting insulin, they know it and they know how to correct it. I mean, that's true with any pump. But that, to me, is always my big concern, is that they're not getting insulin and they end up in the ER in DKA. If you can get past that and see, the islet would be the best option. But you have to get past that issue. If you're not getting insulin, are you, you know, are you good enough that you'll check ketones and know what to do for a sick day management? Have you ever given, like, Degladex with an islet? Not yet. But the Degladex, you know, I just, you know, I tell the fellows, I make it up when I go in. I have no idea what I'm gonna do. And I just, with that one patient, I just did that. So let's get rid of the DKA first. And it worked. Yes? For your patients that have elevated hemoglobin A1Cs for prolonged periods of time, and you put them on an AIB system, and they get improved control with a short amount of time, what do we do? Are you concerned about the, like, iritis, or, sorry, the retinopathy, or the neuritis? Boy, this is, yeah. Again, this is a 20-minute discussion about the worsening of the retinopathy. Let me give you sort of the bottom line. This has been a real, real interest of ours in Seattle. The bottom line is we, first of all, if there's no retinopathy at all, it's a non-issue. You see somebody with newly diagnosed diabetes, it's a non-issue. Secondly, we don't see it as a rule of thumb unless the A1Cs are in double digits, unless they're really, really bad. And that may be one of the reasons why where this is seen the most is in the diabetes and pregnancy clinic, where they come down very fast. We're actually seeing it more in our type 2 patients going on a GLP-1, not because, not because, and I have to stop, not because the GLP-1 is doing the problem, but because these A1Cs are coming down so fast because these patients aren't eating. But it's a huge issue, it's a huge concern, and my very last patient I saw this week before coming here, she's somebody who had an MI, she's a type 2, she was put on basal bolus insulin in the hospital, and this is an amazing story because we don't know how fast these cotton wall exudates go and come. The cotton wall exudates are pathognomonic of what happens with these microinfarcts in the retina when they come down. Less than a month after she went on basal bolus and brought her GMI was in the normal range from initially A1C of 12, the cotton wall exudates were there. It was just by chance she was seeing the ophthalmologist. They then went away a few months later, we then brought her blood sugars down, she was on ozempic, and now she has cotton wall exudates again as of this week. So, yeah, it's something we're still learning about, but you have to be careful. My time is up, I hope you all found that helpful. Thank you all very much. Thank you. Okay, so next up we have our Career Pathways panel. So if all of our panelists could come up and go ahead and have a seat at our table. And Dr. Chow is actually going to lead the session from the podium, so I'm gonna be doing intros from the table. Little logistical shuffling there. Okay. Okay, so while everyone gets seated, I'll go ahead and start with our intros. I'll start with Dr. Chow since he's kindly agreed to lead this session. So he's a clinical professor of medicine at UC San Diego, a clinician at the VA San Diego Healthcare System. He's the principal investigator of studies applying human-centered design to diabetes technology so that devices such as CGM are more accessible and engaging. He worked with UCSD nano-engineers on developing wearable non-invasive glucose sensors. And as co-chair of his division's research subcommittee, he helped spearhead innovative measures to help faculty start, sustain, and spread their research. Doctor, who's next? Let's see. Okay, doctor, how do I say your last name? Raden. Thank you. Dr. Raden is an executive medical director and responsible for leading the US medical director team across Novo Nordisk diabetes portfolio. He received his MD from the University of Connecticut and completed fellowship in endocrine, diabetes, and metabolism at the University of Pittsburgh. Prior to joining Novo Nordisk in 2016, Dr. Raden worked in clinical academic practice for 10 years. His practice largely focused on caring for patients with diabetes, and he was actively involved in educating and training medical students, residents, and endocrinology fellows, and was also actively involved in clinical research. And he currently lives in New Jersey with his wife and two sons. Might flip back to the first page, okay. Dr. Huang, is that how I? Huang? Huang. Thank you, Huang. Sorry, I was not supposed to be moderating, or else I usually ask everyone how to pronounce their name first, but I'm winging it a little bit. So Dr. Huang is chief of the division of endocrinology and metabolism at UNC Chapel Hill, associate professor of medicine and cell biology. And as a physician scientist, Dr. Huang's academic interests are at the intersection of metabolism and neuroscience. Her research focuses on using advanced brain imaging modalities, such as functional MRI and magnetic resonance spectroscopy, coupled with classic investigative techniques in metabolism to understand the effects of diabetes and obesity on the brain. Okay, Dr. Socio. Socio, thank you. Is a physician scientist who in 2021 joined FDA's office of new drugs, division of diabetes, lipid disorders, and obesity. He reviews drugs for lipid disorders and obesity and was the primary clinical reviewer for the 2023 approval of terzapatide for weight management. He completed internal medicine residency and endocrinology fellowship at the University of Pennsylvania, where prior to joining the FDA, he was a tenure track assistant professor. He was principal investigator of an NIH-funded lab, directed an adipose tissue bank, and started a clinical practice focused on obesity management in patients with metabolic dysfunction, associated fatty liver disease at the Philadelphia VA Medical Center. He lives in Bethesda, Maryland with his wife, Dr. Costello Socio, a dermatologist at NIH, and their three kids. And last but not least, my boss. So Dr. Haller is a pediatric endocrinologist with a passion for patient care, teaching, and research. He's a Gainesville native, go Gators, and proud graduate of the University of Florida's College of Medicine, Peds Residency, and Pediatric Endocrine Fellowship Programs. And in addition to serving as chief of pediatric endocrinology, Dr. Haller coordinates an active research team focused on the prediction, prevention, and reversal of type 1 diabetes. He's an active investigator in type 1 diabetes trial net, the TEDI study, and the type 1 diabetes exchange, and has published over 200 peer-reviewed manuscripts and book chapters, and received over $10 million in research funding over the last five years. All right, so we've got a great panel, and I'll let Dr. Chow take it over from here. Dr. Chow Thank you so much. Good morning, everybody. So you may be wondering, the person who flew the longest to get here gets the podium, gets no chair. So, which is fine by me. So welcome, everybody. It's great to be here, and thanks for taking time to join us. We look forward to a great discussion. And the big question is, who would like to ask the first question of our distinguished panel? Can I start? I'm always really interested in hearing how everyone got to where they are, and if, you know, in your mind, when you were a fellow, was it always your plan to, like, work for the FDA, or work for Novo Nordisk, or, you know, do academic research? You know, I've heard from others in different fields that their paths weren't quite so straightforward, which I think is nice to hear sometimes, but maybe you had a very straightforward path, and I think just hearing people's paths is interesting. Sure, I'm happy to start. Well, yeah, we'll go, we'll go. So, yeah, thank you all for being here. It's super exciting to see the next generation coming up, and I always love this meeting. So my path to medicine was pretty clear. I knew I wanted to be a physician pretty early in life, but I did not know I was gonna be a hardcore academic research person. I really went into medicine initially thinking I would be a clinician educator. Through early years of med school, I still thought that was the case, but because of relationships, which is, like, how everything works, I worked with Des Schatz from the time I was actually a teenager, because I grew up in Gainesville, and our families happened to know each other, and he kept encouraging me to come, you know, spend time in the lab, work with the diabetes prevention trial, which eventually became DPT, and I found I was actually really curious about asking questions to try to move beyond standard of care, and almost because of that curiosity and Des' mentorship, I just couldn't help myself, but I kept finding myself wanting to be more involved in research, so that and experience as a diabetes camp and my own grandfather living with type 1 were, made it clear I wanted to do pediatrics and then endocrinology, and along the way, I started picking up more experience in clinical trials. I spent some time in the basic science lab and doing animal work, and fast forward 25 years, and now that's what I spend more of my time doing than anything. I still always do it with a focus on patient care, because that's my interest, and that's sort of my biggest passion. They always tell people, if I had to give something up, I would actually give up the research stuff before I gave up taking care of patients, but really, that's how I got to where I am, and now I do some more administrative stuff as well, so that's another interesting thing that you can take on as you get through your career, and I didn't ever really expect to do that. It just kind of happened, but that's how I got where I am. All right, I'll go next. So I work for FDA, and I've always wanted to be a regulator. That's the thing. So it's obviously something that not a lot of people think about. For my whole career, I was on the straight line, a physician scientist. I did a combined MD-PhD. I did a short track residency into endocrine fellowship. I was an instructor for an ordinate amount of time than assistant professor, and for some reason in 2021, I veered off of that pathway. It might have had something to do with the pandemic that was going on at the time. I was running a basic science lab, very hard to do science there. Getting funding is always a challenge, and so I started looking into other options, and that's when I first even thought about FDA and regulation as a career. So with three years of hindsight, I think it was the right call for me, and yeah, I don't wanna take up too much time now, but during the rest of the session, I'll hopefully tell you a little bit about what it's like to work for government and regulation and how rewarding it's been for me. Wonderful. So hi, everyone. So I guess my path was sort of similar in the sense that I think everyone in this room probably chose endocrinology because you love physiology in a certain way, and you love to understand how the body works and taking care of patients in that context, and I think that's how I came to the field of endocrinology just because I was just really curious and enthusiastic about understanding how the body works, and I started off being very interested in basic science, but then during internship and residency and then fellowship started to realize that that was a little bit too removed for me from what I loved the most, which was talking to the patients and understanding their experience, and so I sort of gradually moved towards clinical research, and I would say that the area of clinical research that I kind of live in now I find incredibly fulfilling because it's sort of, I would think of it as as close to physiology as one can get. It's mechanistic, human-based research, and so for these type of studies we do, it's really the classic things, oral glucose tolerance tests, hyperinsulinemic clamp studies where you kind of get to know the participants of the study who are oftentimes patients. You get to know them over a long period of time, you can see physiology at work, you can take that opportunity to talk to the participants and teach them about their disease, and I find that incredibly rewarding, and I take it back to my patients in clinic all the time, and so I think fewer and fewer people are going into this sort of area that kind of spans, it's really basic science, but it's basic science with active participation from your patients, and it's a really rewarding area, so I'm happy to talk a little bit more about that, but that's sort of how I got and have sustained an interest in research. It's not a totally easy life, and so you have to be really passionate about what you're doing, and then over the last couple of years I've sort of taken on some additional hats in administration, and we can talk about that too, and then the final point I'll make is that I have found a career as an academic clinical investigator to be incredibly synergistic, well, maybe not synergistic is the right word, but it's very compatible with family life as well, and so I'm happy to talk about that as well. Cool. So for me, no, I had no thought whatsoever that I would be sitting where I am today when I was in your shoes. I, much like you, I just fell in love with endocrinology from an anatomy physiology professor in college, actually, and then so I pursued internal medicine and then during my residency there was an amazing endocrine faculty, and again, I was like, oh my God, this is just what I want to spend every day doing, and I ended up in what I thought was a pretty academic clinical tract, and I thought that was exactly where I was gonna be, and I was in what I would have told you really was my dream job, so I was spending about half of my time seeing patients. I was medical director of our health systems diabetes program. It was fantastic. I had time to spend with patients. I had educators. I had everything at my fingertips to do real team-based care with patients, and then I had tons of teaching opportunities between our fellowship and our residency program. I was investigator in a number of clinical trials, which I love to do, so it was really my dream job, and a much longer story that's much more fun over a glass of wine or something, but the short version is I needed to relocate for family reasons, and at that point, I was in my dream job, and I'm like, I don't want to start over again, another clinical job. I can't imagine there'll be anything this good, and I was alerted to an opportunity in industry from a former colleague and a friend of mine who I did my residency with, and so I ended up at a job at Sanofi for about a year and a half, learned a ton, wasn't quite the right fit for me, and then learned about this opportunity at Novo Nordisk and have been at Novo ever since then, and I would say in an alternate way, another dream job. I'm happy to share, but I work with really smart people, learning new stuff every day, and feel like I get to be on the cutting edge of new therapies for patients, which is something I always love to do in practice. Hello, everyone. So I actually had wanted to go into academia. My mentor was the late Bob Henry up at UCSD, and I was inspired by him and his team, and I think what was surprising to me was not necessarily doing the clinical trials that I was doing before, but also looking at the kind of newer direction I've been heading on as far as working in nanoengineers and then looking at human-centered design as far as involving patients, healthcare professionals, and every stage of the research department. So very rewarding and unexpected. All right, I'm gonna take the prerogative as the moderator to ask one more question, and then we'll open it up to everybody, but you all kind of touched on this a little bit, but the unique aspects of your job that are either really well-suited to you as a person or you think just make your job really exciting and something you look forward to doing every day. I guess I'm a little bit similar, but more early career, but when I went into more of a research focus, I am an introvert, and I think the time that I've been able to write and read and do those sorts of things have fit my personality very well. Like I, again, initially went in thinking I was gonna do clinic and be more of a clinician, and I think if I had to do clinic all day, every day, like I would burn out so quickly. So I think that was sort of a personality thing that's fit me. And then just some unique things that maybe make your job either fit you well or make you excited to go to work every day. Yeah, I think that's like the challenge of your career, right, is to figure out what is the best use of your time. We all have limited time on this planet, and you gotta do things that fit both your passion and your skillset and your family life and all those things. So my problems are like everything, and so there's just not enough time in the day, right? And so to be successful in a research track, certainly academic clinical research track early on, you really have to put in the time or else you just can't get enough stuff done. So, and that was a struggle for me. I mean, I have to admit, as much as I liked looking at those questions and answering them, I wanted to do more clinical time. So it fits my personality because I really love to be a problem solver and I like to try to fix things. And so, you know, current clinical practice isn't good enough. We'd fix it by doing research. I really liked the patient facing stuff. I didn't think I liked writing, but I do. So I'm sort of like an introverted, extroverted, extroverted, introverted. And so I like the same things that Brittany does in terms of time for that, but I don't want it all the time because I like to see patients too. So, and I think I'm just, I ended up doing administrative stuff for the same reason. I think, you know, people say, well, there's a structural problem. I always like to try to fix things. So I ended up getting involved with them whether I wanted to or not. And so then it just ends up being how you divide your time. So, you know, on paper, I might have 75% research time and 20% admin time. Actually probably see as many patients as somebody on paper who's 20 or 25% clinical, just cause I won't give that up, which does make it challenging to get everything done. You certainly can't do academics and be successful in research without writing grants and papers and reviewing things on nights and weekends, but you do it cause you like it. Yeah. So, so I, you know, I had obviously years of experience in academic medicine. And one thing that I've very much liked about coming to FDA is that in academics, especially trying to do basic research and clinical care, that there just wasn't enough time in the day to do everything that I wanted to do and to do it well. And so making the move into government, so not just FDA, but I hear the same thing for, you know, NIH and other government agencies is a very, it's a very well-defined job. You have a role that you have to be good at. There are, it's very collaborative and team-based. The other roles, other people do, in terms of the amount of time you're expected to work. It's, it's 40 hours a week. You have to fill out a time card and put what you're doing in this, you know, bureaucracy and government is expected, but you're given the time that you need to do a thorough job at what you're doing. So in terms of the types of things you bring to it, being very, you know, being very detail-oriented, really wanting to delve into the, you know, the applications that you're getting and really knowing the science, knowing the clinical studies, like Michael said, being on the cutting edge of new drug development. And, you know, before I came to FDA, I probably had the perception that most of you have, that you're kind of the referee, the umpire. You're calling, you know, the regulatory decisions, but you find out very quickly that the role is almost just as much being the coach. But we have so much back and forth with Pharma on trial design and on, you know, how they're going to conduct their development program. And it's very impactful. We give advice through the whole life cycle of the drug, from first in human to post-marketing. And it's very interesting. You have a lot of different drug products with different mechanisms. Michael's company is keeping us very busy in diabetes and obesity. It's an exciting time in the development of these drugs. We're definitely short clinical reviewers right now with all the workload that they're giving us. So compared to clinical medicine and running a lab, I think this might be the ultimate introvert job. You know, every day I have a few meetings. It's mostly telework. I go into the office once a week and see people in person. There'll be a few virtual meetings every day, but it's a lot of time, you know, sitting at your computer, reading, writing. Your communication skills have to be like top-notch. You have to communicate very clearly. You have to be able to, you know, synthesize a whole lot of data concisely, and so yeah, being that type of a detail-oriented work on your own through problems, I realize it's definitely not for everyone. I wasn't sure if it would be for me. I know personally my wife, who's also a physician, would go nuts doing this. She needs to be up and about seeing patients all day, but for the right kind of person, which it was for me, for those reasons, I've liked it a lot. I guess before I say, I know there were some graphics about people's interests here, but how many of y'all are actually interested in staying in academia? It's many, yeah, yeah, okay. So yeah, I would say, I mean, I'm going to just kind of echo what everyone else is saying that you kind of have to know what your interests are, but one of the things that, for me, is really advantageous about staying in academia is that it keeps the door open to many, many paths, and it gives you a lot of flexibility and control over how you choose to stimulate your brain, basically. There's many other things that you can do, and so I think for me, that's one of the biggest benefits. Maybe I'll just keep it at that. Yeah. I think I share a lot of similarities with my colleague's stories here too, but for me, so A, in a broader discussion, if you open the bucket on pharma, there's so many different types of roles that I think you can find something that fits every personality. I don't know if anyone's done the whole HDBI personality thing, but we've done it, and we've done it where by function, you have people fill it out, and then you have them stand where they fit on the chart, and my God, it separates out by function like almost 100%. It's really interesting. So for me, in medical affairs, it's really a bridge. We're somewhere in between clinical development, which are running the clinical trials, and then the commercial team that's out there trying to reach and educate physicians and patients. I think for me, what I love is I get to ... It's a cross between I love clinical endocrinology, and I love new drug development, and I get to do both of those things all day. So one hour, I'm talking with our colleagues in marketing and giving them recommendations based on my own clinical experience and expertise, and then an hour later, I'm reviewing a protocol on a new study that's coming in and giving input on that based on my days working in clinical trials, et cetera, et cetera. So I kind of get to do a whole lot of different things, and I think to Raymond's point from a quality of life and a work balance, I mean, I definitely ... There are times ... There are many times, after hours, nights, weekends, I'm doing work, but the difference is it's on the time that I determine. So I won't miss any of my kids' events because I can read something or answer an email at 10 o'clock at night. I don't have to do it right when their stuff is going on, and that kind of flexibility has been pretty awesome. Yeah, so I think one of the surprising things was getting involved with health-centered or human-centered design, and I'm curious how many of you are familiar or have any interest in health, human-centered design, or ... All right, good to hear. And I think that's one of the things, right, that I am excited about is trying to get the word out, trying to get more people involved in working together with it. There is actually a first annual conference in the University of Nebraska this year, this coming fall. So it's a very emerging field, so much so that when we were doing our first posters, we were thinking, who do we submit these posters to? And the ADA was the first organization that came to mind, and when it came to a manuscript, you know, who do we submit to with this kind of field? And I think it's always ... I always say you feel young because you're always learning, because you're always a student, no matter how many years you've been doing this. So I think that's what keeps me energized and keeps me enthusiastic. All right, thank you. All right, I'm going to open it up. Anybody want to be brave and come up to the microphone, or ... I guess you can ... Yeah, if everyone can hear. Can everyone, like, hear from the other sides of the room? Okay, perfect. I have a question, if you're not minded. Maybe a mic is better? Yeah. Actually, let me grab this mic right here. Thanks. I have a question for you, Dr. Radin, about industry. So for recent graduates out of fellowship, what does the industry really look for in terms of prior skills or accomplishments, you know, if someone's looking for transitioning into an industry role? And I think the second question is, what kind of roles should someone be looking out for? Is it just medical affairs, or are there other roles? And I'm talking from a standpoint of clinical adult endocrinology with, I would say, a pretty decent experience in clinical trials. That's a great question, and I think it depends what you're looking for. So I think one, you know, one role that having a little bit of, this is my own personal advice. Having some clinical background treating patients beyond just fellowship, I think, is hugely beneficial. It doesn't have to be a ton, and it's not for everybody. If you know, like, hey, I'm not going to go do that, and I want to see what my opportunity is here, that's fine. But the reason I say that, so I think one skill set that's always critically important is really good communication skills. I think exactly as my colleague mentioned, too, because you're communicating with people across multiple different backgrounds, and you have to be able to do that very clearly and do that knowing your audience. So you can speak very differently with a fellow endocrinologist, and you're not going to speak the same way to somebody who works in regulatory affairs, for example, who might not have any of that kind of background, versus someone in commercial or sales who doesn't have that kind of background. So really good communication skills are definitely looked for. And then any kind of clinical and or clinical research experience, depending on what you want to do, is a big deal. So for example, in medical affairs, many people, their first way in is to be a medical liaison, where you're, many people don't, does anyone even know what a medical liaison is? Because I see, I'm glad someone's brave enough to shake their heads. Many people think a medical liaison is a sales rep, and they're not the same. So I think everybody knows what a pharmaceutical rep is, a sales rep. They work for the commercial side of the organization, and their job, they go in there, they tell you about a certain drug, et cetera, everybody knows that. Medical liaison, they're on the medical side of the organization. There is no, there's no tie to sales whatsoever. There's a huge firewall between medical and commercial that way. And they meet with HCPs who are identified as, you know, thought leaders in their area, and their job is not to sell a drug at all. It's literally to go in and do what we call scientific exchange, have a dialogue. What do you need to know? What do you need to understand? Do you have questions that we can answer? Are there research ideas that we can discuss together and bring in? Very different kind of role, but one where you can have really great discussions. So obviously having some clinical background where you can relate to another person practicing endocrinology helps a lot. Or on the research side of things, having, even if you've done research as a fellow, that's great because you have some research experience and you can bring that in. So that's sort of a super short answer, but. I'm going to jump in and answer that question for FDA because the answer is, the answer is very similar. For the clinical reviewer position, which I am, very rarely people come right out of fellowship to this type of a job. But again, my personal advice is the same as yours. Having a few years at least of independent clinical practice after fellowship is invaluable. And that's usually what we're looking for. Experience in clinical trials is also something that, you know, during fellowship or afterwards is definitely something to pursue as well. I was coming at this from a basic science perspective and I was like, hey, I'd done all this basic science. You know, they were more interested, you know, had you worked with an IRB and I happened to run an adipose tissue bank and I was the PI on that and the FDA is like, okay, we need something on there. But so yeah, some clinical research and yeah, during the interview, they're looking for communication skills and teamwork. Everything is so team-based. Are you going to fit in and be a good part of the team and communicate clearly? And so yeah, a very, very similar answer. Anybody else? You can get your steps in today. Hello, everyone. So my question is maybe quite general. So I'm Sook Chin, by the way. So I just like to ask, is there any advice on the timing to a transition, for example? Does your previous experience really count? Or say if someone is interested to transition into, what is that, industrial, for example. So do you advise to transition early or maybe after you have gained some extensive experience, for example? Yeah. Thank you. I think, and certainly feel free to chime in, but I would personally advise, again, I think it was really helpful to have a background of clinical experience, certainly from industry and sounds like very similar from a regulatory perspective as well. The more experience you have that you can draw on, the more, I don't know if valuable is quite the right word, but really, because that's the experience that you're relying on. So if you've had multiple years of clinical practice and you've seen all kinds of patients and you have that expertise under your belt, that puts you at a different level of knowledge and understanding. I think if you have participated in a number of clinical trials, it's different if you've just been a sub-investigator on a couple of clinical trials versus you've been a PI on a number of clinical trials, that puts you in a different position in terms of the expertise that you can bring in and offer. So I would say as a general rule, that's the case. However, there are programs in industry, they have, they're essentially fellowship programs that they'll take you right out of your training and you'll do sort of like a one-year or two-year fellowship rotation with an industry company and get exposed to different roles. And then that can be an opportunity to then find a job afterwards. Those roles, those fellowships exist, they're few and far between. So they're not a ton of them, but that's another way in. If you're kind of more certain that I don't want to put five or 10 years into clinical practice and I just want to go, that's another way to look at it. Very similar, but I'll also use this opportunity to address the training that you need to make the transition. And in academic medicine, I certainly didn't know a lot about regulatory science and regulations. And I think it's the same way in pharma. There's just a ton of on-the-job training where at FDA, there's just pretty much courses that you go through that teach you how to do this stuff, because no one kind of has that background. And yeah, so the training is well done. No one comes into the job knowing it. You learn by courses even more by doing it. And you're never on your own. They're always the team leaders and the more experienced people who are helping you along. It's not competitive at all, it's 100% collaborative. Everyone wants to help everyone else out and the training is very good. So that makes it a real transition possible. And I probably didn't have a full, when new people come on, you probably don't have a full workload until a year later, they gradually start adding things to your portfolio as you get better at the job. So it makes the transition better. I just want to echo what you said in terms of all of that, the collaboration, it's not a competitive environment. People are there to help you. You learn on the job. I'm loving to see the similarities across industry and FDA, so I'm really enjoying this. Yeah, it is very similar. And to your point about flexibility for what you can do in the future, I could certainly go back into academic medicine at some point. I think the skills that you get in FDA make you attractive candidates for jobs in pharma down the road. So it still has a lot of that flexibility to, though, staying long enough to get a government pension is not a bad thing either. I have a question for you all. How do work and life, work and home life, excuse me, kind of influence each other? How's the integration of both factor into your guys' and your all's careers? Any advice? Work and home life, yeah. So my wife's a physician also, and we have two kids and two dogs. And clearly, family life is super important to balance with your career. And it is admittedly hard, I think, for most of us in the room who are type A and go into medicine and want to be productive in whatever way you decide that looks like. So one of the nice things about being more research than I thought was kind of for Brittany's point, like, while I work a lot of hours, I get to choose when I work them. Because if I'm not with a patient, I can decide to go to my kids' graduation ceremony or be at their play or take them on a trip because I can do the work other times. So it does provide some additional flexibility, and it's part of why I've liked to chunk up my time in terms of administrative and research and clinical. But that's not to say it's not always a challenge. And I certainly answer lots of emails and do charts in the evenings, but I've tried to be better about making sure that I make enough time to turn it away and just have to make sure you find that balance that works for you. My wife's an anesthesiologist in purely clinical practice. The minute she leaves, she's done. So she has none of that kind of work, and it helps to remind me that I don't have to always do that also so that we make time for ourselves. So I would say that government and FDA is kind of the ultimate in work-life family balance. I struggled with this in academics, to be honest. There was just always the expectation that you were there nights and weekends. When I was doing stuff with my kids, you felt like you're supposed to be writing grants and papers instead, and it was kind of untenable. And so this was a big reason why I made the switch. Right now, it's mostly telework. Like I said, I only go in once a week. You can do your hours whenever you want them, as long as you're getting your work done. If you do extra work beyond the 40-hour week, you get credit hours, which are just pretty much like overtime that you can use to take time off at other times. So if you're really busy with something and working extra, then you can accumulate some hours and take time off later on because there's like an ebb and flow to the work. So yeah, I coach my kids in baseball. I coach my kids in basketball. I never miss anything with them. Most days, I'm home when they get home from school. Sometimes I'll have a sign on the door, in a meeting, do not disturb. But I can't imagine a better work-life balance than what I get at FDA. Oh, goodness. We can't compete with that. Sorry. You're studying academics. Yeah. Well, I'm at UNC Chapel Hill. I'm the division chief there. But I've been in academia my whole life. I would echo that there's a lot of flexibility. I think we can all, I think everyone here could probably say that if we need to be with our kids for a certain, like if you're in a moment where you need to go to the bathroom, bathroom. And I think that's really helpful is, you know, of course having a supportive partner. So my husband is in academic medicine, I have two children as well. I don't have any pets, but I have plants that I try to keep alive. But the other thing is to find colleagues at work who can be your partners there. And so I've been very fortunate in my research life to have had some incredible collaborations with some other women who are kind of in the same situation as me. And we kind of, we would cover each other's studies. We would, you know, you just want to create layers of additional flexibility for yourself. And it's very rewarding in that way, and makes it more fun, and it's very team-based. And so that's another, just another little nuance that has really helped me. Yeah, I think I'd echo a lot of what my colleagues have already shared. I would just say, so there's definitely work-life balance. At least I would say at Novo, that's a priority from leadership and top down for work-life balance. But to some degree, you have to take it into your own hands, because there's enough work to just do it 24 hours a day, seven days a week. Like the work doesn't go anywhere. And I imagine most people in this room, as a room of physicians, are type A personalities. So that's just what you're going to do. So when the email comes at 5 o'clock on Friday, you don't have to do anything about it, but your brain can't help yourself. Or like, no, I need to get, I need to take care of this now. So I would, just a life advice for everyone, find a way to turn it off. There's always a way to turn it off. Whatever you end up doing, find a way to turn it off and prioritize that. I think it's really important for mental health. I think you show up better to work and with your colleagues when you make the effort to do that. So. Yeah. At FDA, they tell supervisors if they send an email late to put a timer on it so it doesn't get you to the next morning. That's awesome. But I think that's a really great point. I just wanted to echo that. I think everyone should set, you know, there's this myth that in, you know, that if you're constantly in, you're writing grants and you're constantly working 24, but it doesn't have to be that way. Like my husband and I made a rule for ourselves that we would not work at home when the children were awake. And we've lived that rule for the last, my son is 13. So we've lived that rule for 13 years now. And it hasn't hindered us to my knowledge in any real way. And it's been really wonderful in that regard. And then also, I don't know, this might sound a little cheesy, but I've always used a personal litmus test. If I'm going to pick up something at work, is it worth the time to take away from, for me, it's my children, but it could be anything else, you know. And you can set those parameters. And if you're disciplined about it, then you're actually setting a good example for, you know, other people that you work with as well. I think burnout is a real thing. And you don't have to work to that capacity to put out high quality work. So I think that's another thing that we all have to play our part in kind of setting the right tone for that. Well said. I certainly can share, although I feel strange to answer the question that you threw out. I have to echo what everybody's saying. I mean, there's flexibility in academia as well, where I am. Having a great understanding spouse is important, but I always think ever since our kids were born, we have two girls who are 12 and 9, you know, the kids won't stop growing. You can't really make up that time that you trade off, as you all are saying. So I think that's the number one thing is, as time goes on, you can't really make up this time, you know, this bolus, right, later on in the week. I guess you could, but it's probably not the same to the kids as they look back later. So I think it is possible. It's not easy, but certainly it's a balancing act, because with all things in life. Somebody here had a... Yes, please. Hi. Thanks for coming. I had a question. So a lot of careers in endocrinology and a lot of the career advice we get is on developing, you know, the newest therapy or guidelines or, you know, trying to push things forward. But I think a lot of experience that we probably all have clinically is access is a huge issue to everything. Obviously, there's huge pricing issues with insulin, the newer therapies, GLP-1s, and drug shortages now is becoming more and more increasingly a problem. And so I was just wondering, in your respective jobs and organizations, do you see people working on that? And what does that kind of a career look like? And any advice you have for us on trying to further that part of the field? That's a great question. That's a really good question. Yeah, that's a great question. I mean, so I can speak a little bit from my vantage point at UNC Chapel Hill, where our mission is to serve the people of North Carolina, right? And there are big discrepancies and there are areas where there's just no access on top of all the other sort of more national sort of things that we struggle with. And so I think, you know, there's several lines that you can pursue. You know, I think one silver lining of the pandemic was that it kind of revolutionized our acceptance of telemedicine technology. There's still a lot that needs to be done in that area about how do you deliver that and how do you get healthcare systems to buy into that and compensate that appropriately. So I think those are all some areas that I think we need more work in. And then also, you know, how do you work better with... So we're based in Chapel Hill at the medical center, but, you know, there's across the state of North Carolina, for example, there's, you know, the local, you know, health offices and, you know, from the state, how do we partner with them a little bit better? So there's a lot of ways that you can work, you know, work those lines as well. So but it's a it's a multi-pronged very very difficult area that needs a lot of attention and work and people are working on it but not nearly enough and then I won't even go into AI and the potential for that. Yeah I think advocacy is a big part of what certainly most pediatricians do but people in adult medicine do as well for all those reasons and it's it's I consider it a core part of our job. The biggest challenge is getting funding for your time to do it so you know if you go work for Breakthrough Type 1 Diabetes, formerly JDRF, or you go work for the Helmsley Trust or I mean you can you can work for organizations that provide money to make changes in areas of disparities or even work on lobbying but those are those are pretty few and far between. So what I think what I end up doing is using some of my admin and research time to do that advocacy work and I've actually built in a fair amount of my academic career in terms of the research stuff we do into advocacy work so you know like the Helmsley Trust funded an ECHO project for us where we focused on ECHO diabetes teaching primary care docs at federally qualified health centers how to take care of diabetes better and showed really nice outcomes. You know so that's just an example of how I turn sort of an advocacy tactic into into research work and there are areas of advocacy that I never thought I'd have to get into. Like you know obviously as a pediatric endocrinologist and we have a gender care program and like fighting against our own state like nobody's gonna pay for that work so you just have to do it because you have a passion for it. So I'm not sure if there are other folks who have ideas on how to make that like a full career if that's your interest but I think it's an important part to put in because it certainly gives flavor and value and you feel like you've done something you contributed by participating in those things. It can't feel like you're up against a big wall though because again nobody wants to pay for advocacy. So one other thing I sometimes counsel my faculty and then I've seen is that you know sometimes for these sort of things that don't intrinsically come with funding you kind of just start small you know if you're a faculty member if you're junior fat you just joined and you want to you know work in this area you just start small in your own clinic or your own division and in general I have found in my life that if someone sees something that's successful and you find and you sort of keep kind of records find ways to quantify what you're doing and work with your division chief on that then it is much much easier to advocate down the line for some additional funding within the division within the department or something to kind of grow a program and then you kind of let it snowball that way you know so I would so I found that to be generally the the only successful way to go for this kind of thing. And there are a lot of federal dollars also for disparities work in terms but again you have to have a research bent to it if you want to do that although we've worked with our like our State Department of Health that's not really researchy but there can be dollars available to do work there too. I appreciate the question and I'd share from my perspective it's it's a very significant issue that's top of mind I know for us as a company and I'm sure for many others as well and it is a multi-pronged approach I mean without without going to diatribe there are many misconceptions and misunderstanding of the health care delivery system in the US it is broken on so many levels but there's also just a lot of lack of awareness of how it actually works where the dollars flow etc and there are multiple parties involved in that but in short we have many teams across many places working on to to improve it because it doesn't matter how good your medicine is if the patient doesn't have access to it it doesn't matter so so it's something we take seriously so it's whether it's the team that's negotiating with insurance companies and payers for coverage it's policy it's exactly that it's going to Capitol Hill and educating and what are the opportunities there it is sponsorship for exactly some of these organizations we do a lot with ADA with Breakthrough T1D with other organizations to help provide some funding to help with their advocacy and their efforts our medical team goes out and works within individual health systems whether it's University of North Carolina or other health systems to on a local level try to understand in that health this health care system what are the barriers and are there any ways that we can partner or contribute to a solution so it will take a multi-pronged approach from all the players involved to to address it so so yeah the the cost access and equity are obviously a huge problem that we're facing at FDA as well we don't have a lot of tools from Congress to address some of these for instance FDA is the only regulatory agency in the world that doesn't take cost into account every other country with a national system as a cost-effective analysis to approve our standard is safe and effective which is how you can get some therapies of marginal efficacy and high-cost approved but then it's up to insurers and guidelines to say whether the drug is actually used and covered in terms of the shortages you know it's kind of a unique case for for these drugs right now usually the laws for shortages are written for drugs that are in shortage because they're not profitable to make and now we're having shortages because the drugs are so popular and so profitable they can't make enough of them and so the the rules aren't really built for that you know we can have a shortage list which allows compounding but as I'm sure you're all aware the the compounded drugs are not inspected for safety and quality the way that the other ones are though so yeah we don't have a ton of tools to address that and it is probably going to take advocacy in Congress to help address that in terms of equity one thing that we're requiring now in all phase three programs is a diversity plan to assure that the clinical trials are representative of the US population so sponsors have to you know put in a plan to make sure that they're recruiting from a representative population with with that disease and so we have to review those and and make sure the trials are representative but yeah cost access equity are just the big problems from every perspective if I may add just the importance of the community organizations right the grassroots folks are out there what creative solutions highlighted in the health equity symposium I believe there's one this year just like last year like an organization in Chicago I forget the name but they go out and provide the medications they provide the testing or reminders about testing to folks in their communities meeting them where they are so our group has been working a community local advocates as well and experts in the field of yours so I think it's it's a all these efforts combined we'll start making progress but I was just gonna throw in I think you could make it your whole career like if you look at the articles published in JAMA if you did a research career based on you know access you could do that for me that's not like my whole career but I am passionate about advocacy and so I've thought you know deliberately about how I could turn some of this stuff into like an academic product for promotion later so I'm a I'm co-director of the pediatric residency advocacy rotation which in pediatrics you have to do an advocacy curriculum and so that's fit really nicely and it works with teaching because my to like tenure and promotion things are research and teaching so that's one thing that I've done and then just your work with national organizations is looked highly upon for promotion as well in academics and so a lot of the stuff I do do on my free time unfortunately like you know that sort of time between 5 and 7 p.m. is like when all these meetings happen but I work and I talk with my husband like I'm really passionate about this like what do you think about you know us being able to work this out and and it does look good for you know promotion that you've worked with these national organizations on these initiatives so I'm like part of the ADA's National Advocacy Committee I authored like a top-ten resolution for the American Academy of Pediatrics about insulin access and those sort of things look good on your CV as well and I'm passionate about it so it works together but you do have to do some of it kind of in your your off hours unfortunately who else thanks so much for being here this this isn't so much as a question as a shameless plug I work at NIH I'm a program officer and we are also hiring I don't want to take any of the time here but later find me I'd be happy to talk talk to you if you're interested in working at the NIH if I may for the government jobs are great if I made for the panel um what what's something you would say to your younger self right if you were if you were sitting I wish I had this as a fellow this any scholars opportunity you know what the wisdom with the experience you have now what would you say to your younger self as you were embarking on your career don't take your work so seriously that you forget to live life but work hard I mean it's just all about that balance I've gone through burnout because I went too hard too fast at times and I still struggle with trying to do that so try as early as you can your career to figure out what that looks like for you and know that it's okay for you to be different than other people you don't always have to have a successful career based on you know whatever some pie in the sky a version looks like similar I'd say like try to keep doors open as long as you can but that doesn't mean you say yes to all of them you just open them and look don't walk through them until you're so I mean you need to open them so so learn more say I'd love to learn more about that opportunity do not say yes to everything I made that mistake early too and then just if you have too many irons in the fire you can't keep them all going well and ultimately things will push you in a direction but but you know it can get overwhelming if you don't make that a priority yeah I'd say you know keep your eyes open for for other opportunities through the whole time I you know I spent a lot of time with blinders on thinking only only academic medicine that's all I knew and it kind of took the the major disruption of the pandemic for me to kind of rethink you know what you know work-life balance what type of work I wanted to do and I don't regret anything I did I enjoyed everything all along the way but you know I could have wound up here a lot earlier if I didn't just have blinders on for only one path um I think I'm trying to think of something that hasn't been said yet I think and there's a set there's a session on mentorship coming up later but I would say it that we always think about mentorship is um you know something that's research sort of related but it really isn't I think everyone if I had known tell my younger self the importance of establishing a team of mentors if there's someone who's doing something it doesn't have to be an endocrinology but if there's someone who has an aspect of their career that you find that you admire get to know them usually people love being mentors and and and and I think having a team in my career I've had science mentors you know research mentors I trained under Bob Sherwin for my research but you know I have I've had women faculty who have you know taught me a lot about how to balance family life and and how work life you know other other folks who I've learned a lot about how do you become a better administrator so you just kind of keep keep all that build a team for yourself and it will serve you so well because you know it mentors not only teach you the way but oftentimes they can serve as sponsors too and kind of open doors for you so I wish I'd known that more when I was younger yeah so my career has been successful because I've had incredible mentors but I agree you need a team so you don't get like one perspective you want mentors you want sponsors you want coaches they're all technically a little different and you want to get more than one view finding those people early will really help you great advice for my colleagues I think the only one I would add is is trust your gut and be true to yourself don't make a decision because someone else thinks it's right for you I mean certainly take advice from your mentors and coaches I'm not saying that but at the end of the day trust your gut you usually will make the right decision most of the time and if you don't it's okay you learn from it you move on but trust your gut I think you know I say this to remind myself too but also to share some some words of advice hopefully that can be helpful is to you know learn from pure mentors right people who are maybe at your level your stage your career maybe a year or two ahead of you I think building that community is really important and supporting each other right because you you're all in the same boat but also I think you know it's as easy as this to say I think is bracing the failures right the bumps in the road in your lab and your whatever part of your career I think those are what you learn from the most and I think it's I've read some place we're looking at these kind of setbacks or quote-unquote obstacles with a sense of gratitude right not necessarily you know I gotta deal with this right this this I'd expect a twist or fourth in the road but I think it's more what can I learn from this and then you know use this to perhaps it might be a new career direction might be something that improves what you're doing so I think it's embracing those quote-unquote you know obstacles or setbacks so with that we thank you all for taking time thanks to all our distinguished experts please join me thank you for your questions and discussion enjoy the rest of your scholars time also lady sessions thank you all right so this afternoon's topic is really research funding opportunities for people interested in diabetes related research so we've got some great panelists here's the way we're going to do things I'm going to invite each one up once at a time and then they can go back down very briefly these presentations should be very brief because we've got a lot of additional questions to address from each and every one of you and ultimately when all four are done then I'll have all four panelists come up here and then we can interact with each view out there so let me begin by introducing myself I'm Bob Eccle where should I start you know I went to medical school to be a doctor and I'm still a doctor but ultimately during my house staff training at the University of Wisconsin in Madison I got interested in why people were sick more than why in fact we're using the Washington manual to treat them you use up-to-date today but back way back then we used the Washington manual anyway all that aside so I increased my curiosity and the question then came up what do I do for the rest of my life well I thought research was necessary and the question is which subspecialty and the ever so Wisconsin at that time was incredibly strong and infectious diseases and I majored in bacteriology as an undergraduate student actually had a research experience at a basic science lab I started as a dishwasher at the end of my time as an undergraduate was purifying proteins and doing chromatography and all that kind of thing not that I was any good at it but that reminded me that I knew what laboratory work was all about so as I considered a career choice infectious disease seemed obvious but then I looked at my own personal life and I'll just share with you very openly I've had type 1 diabetes my entire life and I'm 76 now in a survivor in that incredible I mean it's and I really and keep in mind that 40% of my years with diabetes was urine testing only how crude that was inaccurate and ultimately when technology began I remember cutting these strips and quarters because I was a fellow then you know you fellas know you don't make a lot of money so I was cutting these strips and quarters and sticking my finger for the first time in 1979 and from that point meters followed in the next you know decade and ultimately so I thank Earl and the technology he talked to you about as keeping me alive for these years there's no question about better glycemic control it's important in preventing complications which I've had a fair number of so enough about me personally but so the decision to go in endocrinology was this based on the idea that if I don't like research maybe I can be a clinician and help people living with diabetes and of course type 1 was on a relative basis probably not that different than it is today but we have so much more type 2 today because of the obesity pandemic that we're about so anyway all that aside it's had a wonderful fellowship the University of Washington which is of course where Earl is now and I didn't want to do research in diabetes I didn't want to study my own disease but I went to Seattle because it was a strong balance between endocrinology lipid and lipoprotein metabolism and cardiovascular disease medicine and so I got an incredible training experience in Seattle at that time and then Jerry Oleski a name that may ring a few bells at La Jolla at UCSD recruited me to Colorado I've been there ever since I now call myself rewired and as of June 30th 2019 I retired after 40 years of being at the University of Colorado and I'm so busy now I can't tell you and things like this volunteer work with the ADA the HA the African Society and many other organizations and I'm pleased and privileged to have a lab that continues is being run now by Dr. Kimberly Bruce an incredible PhD so it's been a wonderful career that I could not envision when I went to medical school but I I was a clinic physician too and because of my role at the HA as a volunteer ultimately my clinic related to my joint appointment cardiology in the mid 90s and so I always called myself a cross-dresser as a preventive cardiologist because my clinic was in the heart center so as an endocrinologist I was kind of part of this whole kind of cardio-metabolic medicine kind of scenario which is really where medicine's at today can't forget the kidney or the liver in that whole process but ultimately we're very interested in how we might combine additional training experiences for people in that space so that's my background I'll just quickly volunteer the fact that in 1982 I'm a founding member of NAISO which is the North American Association for the Study of Obesity which is now the Obesity Society so that was at Vassar College in 1982 and many of the founding members are no longer with us so we miss them dearly but nevertheless a memorable experience historically then I joined the Nutrition Committee at the American Heart Association in the mid 90s and from there I was involved with Scott Grundy and and Ron Krause in forming the NPAM scientific council of the HA which then morphed now into lifestyle and ultimately I had the privilege of serving the HA as its president in 2005 and 2006 then finally during COVID I was president of the American Diabetes Association and we had no live meetings no board meetings nothing interactive other than you know in fact scientific sessions I think was not done 2020 but anyway that's my experience I've been privileged to be part of science and medicine related metabolic diseases I'm privileged to moderate this session today so we got some great people representing different organizations today and Courtney I'll have you come up first Courtney here oh there she is okay so Courtney is involved with the JDRF and I should mention when she's coming up here she's going to introduce herself by the way all you panelists need to give us a brief introduction and mine was too long forgive me so anyway my first research grant was from the JDRF 1977 and I think you were just kind of beginning of funding research at that time and Ed Bierman my division head I had an opportunity to be funded by the NIH or JDRF and Lisa ignore me on this one but Ed said let's do a JDRF funding mechanism for the first time so thank you very much historically and welcome to the podium hi everyone I'm Courtney Akifi I'm a scientist at now breakthrough T1D big news over the past couple of weeks and uh oh sorry and a bit of an adjustment for us so please be patient with us because I will definitely say JDRF in the next couple of minutes so breakthrough T1D our mission is the same as it always has been where our goal is to accelerate life-changing breakthroughs to cure prevent and treat type 1 diabetes we work across the research continuum we do discover we fund discovery research translational research we have regulatory professionals who really lead the way to smooth the regulatory process to approval and we have policy experts who work to advocate for health coverage for the therapies we develop and we have clinical we have clinicians who work with us to educate the professionals in the in the space so that we can achieve better outcomes we work across the the disease continuum everything from screening to improving the lives of people with established type 1 and along the way our goal is to cure it either through immune modulation or and preservation of the insulin-producing beta cells or through cell therapies so our key priorities within the curing of type 1 diabetes portfolio is early detection cell therapies and disease modifying therapies progression and through our improving lives group which I mostly focus on developing treatments technologies and behavioral health interventions for the maintaining psychosocial mental health of people with type 1 and reducing that burden so the types of grants that we fund for most academics strategic agreements are the standard pathway for funding we also have industry discovery development partnerships these are for for-profit companies that we can also have a fund and then our third program are our Innovatives, which are a single-year kind of transformative, groundbreaking discovery research that are $200,000 for one year. For all of our grants, we highly encourage people to come and reach out to us. We have a scientific staff of, I think, 15, 16, depending on, that have specialties in different areas of type one, and we highly encourage you to reach out if you have a research idea so that we can, we are very strategy-driven, and we would like to make sure that you have the best guidance to kind of align your project with our strategy. We also have training opportunities. We fund career development from the postdoctoral level through early career. We have postdoctoral fellowships, advanced postdoctoral fellowships, and then two types of career development awards for early careers. One for really general, all types of early career, early faculty positions, and then one specifically for clinical researchers. And so this early career, our applications are due next week, I think, so talk to us next year. But please reach out to us. Again, we speak to your mentors and individuals like yourselves regularly about how to develop a project for these types of awards on a regular basis. So our regular, sorry, I'm just gonna, yeah. Our general review process, first, after we generally request a letter of intent from you after those initial conversations, we do an internal review. Letters of intent are either declined or promoted to a full proposal. And through that, it's an ongoing conversation. Breakthrough T1D really prioritizes a collaborative effort so you can formulate a project and a proposal that is going to really have as much impact as possible. And so that process, through the full proposal development, we then have an external scientific review, and our reviewers are really wonderful. They provide really exceptional feedback, critiques, and really prioritize new opportunities to expand and really drive impact. And then we make this final funding decision. This process generally takes around like six months or so, maybe, and then we have our own internal governing processes to finalize funding. But I think that's it. Okay. Okay, thank you very much. Okay, next, Denise Dalton from the Helmsley Charitable Trust. And we not only need to thank her for being here, but also for the support of the Scholars Program by the ADA. So let's hear a round of applause. Thank you. I'm Denise Dalton. I'm a program officer at Helmsley Charitable Trust's Type 1 Diabetes Program. I've been doing this job for over a decade. So I'm really aware of what it takes to improve the lives of people living with Type 1 Diabetes is all the stakeholders, not just Helmsley, not just Breakthrough Type 1 Diabetes, not just ADA, but all of the stakeholders. How many of you identify yourselves as introverts? There was a conversation in the previous panel about extroverts, introverts. Great. Helmsley only gives grants to introverts. Joke aside, I know ADA can be very overwhelming. It's hard to reach out to people that you've never talked to before. But imagine them as a door and open the door to just look inside and learn about their journey. Learn about how they fit into the stakeholder picture, the ecosystem of diabetes. Explore the parts of the ecosystem to find where you can make an impact. Helmsley's mission is to helping people lead better lives no matter where they call home. We are a private foundation. We have about 8 billion in assets that is designed to last a perpetuity. And we thrive ourselves to be bold. In the Type 1 Diabetes space, we have funded T1D Exchange. Probably some of you have heard about that. We thrive ourselves to be high risk-taking. We fund startups. That is pretty high risk. And we also thrive ourselves to be innovative. The Alpha Cell Initiative is one of the innovative approaches that I am proud to say we are funding. And our Helmsley Charitable Trust has six programs, all working towards and with a common thread of health. Type 1 Diabetes is the largest program. And the reason why we have Type 1 Diabetes program is one of our three trustees, David Panzerer, has two daughters living with Type 1 Diabetes, which inspired the initiation of the program about 12 years ago. The mission of our program is changing the trajectory of Type 1 Diabetes. 100 years ago, insulin was discovered. 50 years ago, the first insulin pump was approved by FDA. 25 years ago, professional CGM was approved by FDA. Eight years ago, first automated insulin delivery system was approved by FDA. Two years ago, tablizumab, the first disease-modifying therapy, was approved by FDA. We want to keep that trajectory and the momentum going and rising, and that's our mission. This is the staff that works to achieve that mission. And if there is anything that, you know, if you're working on Type 1 Diabetes, I highly, highly encourage you to look at your handouts that was given to you by ADA. Look at the email addresses of these program officers. Find your interest area. Is it preventing and delaying Type 1 Diabetes? Is it accessing technologies and care in the U.S.? I know there's one researcher that I have to talk to today. Is it global access? Find your passion, find your interest area, and just have a conversation. And that's really important to build relationships in this field because Helmsley is an invitation-only foundation, but you don't need to have an invitation to have a conversation. And we fund projects that are under our strategy areas. Our strategy is built by the gaps. How do we know about the gaps? By coming to these conferences like this, by talking to researchers, by talking to clinicians. And our North Star is the needs of people with Type 1 Diabetes, and you all are a crucial link between us and people living with Type 1 Diabetes. These are some of the past RFPs that we've done, and some of them are coming up that are by our grantees. For example, we have an upcoming RFP coming for diabetes camps. We have an upcoming RFP coming from one of our global access grantees, Panorama Global, for grassroots organizations in low- and middle-income countries. Please follow us in LinkedIn, Facebook, any platform that you'd like to, or check our website just to be informed about these RFPs. They don't come along as frequently as some other funders might send out, but again, the key is to build a relationship with the staff members and the areas that you're interested in and follow opportunities that might be coming your way. We talked a lot about the stakeholders, but it's really important for you to find a person in each of these circles, right? Because each phase of your career will require a different kind of funder. You might have an idea but not have enough evidence. Helmsley can fund that evidence, and then your grant can grow up to be a much larger NIH grant. Or in order to bring therapies to people, you need industry. You need FDA. You need people with type 1 diabetes. So funding that Helmsley started may have been, you know, taken up by industry, and then that's how therapies and drugs gets to people. Or if it's a clinical intervention, you have to convince the Medicaid or Medicare or CMS or the commercial payers to pay for it, and Helmsley can help you build evidence that your clinical intervention actually works, but then you still have to convince the stakeholders to actually bring it to people. So we are part of your solution and happy to give your ideas a boost and take it to the next phase. Again, explore the parts of the ecosystem to find where you can make an impact. So our program covers the entire spectrum of type 1 diabetes from preventing autoimmunity to elderly care because we don't understand how type 1 diabetes develops, so we have to study. Access to 21st-century care and technology is not what it should be in the U.S. It could be so much better, and low- and middle-income countries. That's our Global Access Program's focus. You don't need to be a scientist. I don't have a scientist background, but even I know that this is not a very good-looking map because it shows that we don't have enough endocrinologists here. We have a lot of primary care across the United States. So Helmsley works specifically on expanding the reach of the endocrinologists through telemedicine, through echo programs. Mike Holler actually talked about the program that we funded, arming the primary care doctors with diabetes information, technologies information, CGM information, so that they can care for people with type 1 diabetes. But we also know that diabetes care has to move beyond the clinic. This is a chronic condition. People with type 1 diabetes increasing all the time. We do not have enough endocrinologists. That's why programs like this exist today. We need you. You're certainly on high demand. These are our programs and accessing care and tech in the U.S. There's a lot more detail about the issues that we care about in your packets. And find Amy and me. My colleague Amy, we work together on accessing 21st century care and tech in the U.S. with other program officers that I showed you pictures of and emails of. So find us in the networking session. We're happy to have more conversations. And it only starts with a conversation. And it usually takes like 6, 9, and 12 months to make a grant. Thank you. Thank you, Denise. Our third panelist is Jamie Goodman here from the ADA. Some new insights, perhaps some different ones. I think a lot of the interesting topics for discussion are being covered in part by the presentations. But we'll return to get all four of the panelists together in a few minutes. Jamie, welcome. Thank you. Hello, everybody. My name is Jamie Goodman. I am the managing director. Sorry. I'm the managing director of research programs for the ADA. I've been at the ADA for a little over a year now. Prior to that, I actually worked at Breakthrough T1D for nine years in the research and global access department. And when I was asked by Danielle and Caroline. Sorry, I'm short. I wore like heels. You know, I tried. Yeah. Vertically challenged, what can I say? And when Danielle and Caroline approached me about this panel, it felt like a homecoming of being a decade in the diabetes research funding field. My first big partnership that I was the alliance management for with JDRF, sorry, Breakthrough, was Helmsley and also the NIH. So it's really nice to have this panel. And so thank you, everybody, for being here today. So a decade in diabetes, which is a really great feeling. All right. So ADA, our mission is to seek and pursue treatments, prevention, and cures for all types of diabetes, diabetes, and also fight for the rights of those that are impacted by diabetes. And so research really lives at the core of ADA's mission. And it informs a lot of the programs that we do and also activities. So whether we're advocating for better care on Capitol Hill, for our medical guidance, standards of care information, educational resources, and most importantly, the reason why we're all here today, scientific sessions, research is at the heart of that. And so it's really special to be part of the research programs team, which we are small but mighty. One of these names, Marlon Pragnell, he actually curates the scientific sessions program. So if you see him, he loves to talk shop about science. Please approach him. This is like his Super Bowl. He leads all of our scientific strategies. I'm responsible for all of the funding and grant management strategy and overseeing our two members of our grant management team, Lauren Pincus, who is pre-award, so that's when you're applying, and Angel Rokowski, who does post-award, which is after you're funded. She's the gal that helps you with everything you need relating to your award. All right. So for the last, I think, over 70 years, our organization has provided critical funding to support innovative research and investing in the next generation. And you're going to hear this a lot in terms of ADA. Investing in the next generation is so important to us. So individuals like yourself, we want to bring you into the field. Make sure you feel like you have a home that you can apply to, people that you can talk to, and hopefully stay in the field. Because it feels like every day there's something new and exciting coming out about diabetes. And we need individuals like yourself that are young, have innovative ideas, and can bring a lot to the table to help us pursue the next generation of research and ultimately become leaders in the field. And so with that being said, we support early stage research, so high impact, high reward, early career. We're very big into that, and you'll hear more about two opportunities that we have currently on the table that we welcome you guys to apply for. And then we also do basic translational and clinical opportunities with more targeted research so we can really answer the call of, what's going on in the field right now? Where do we have a gap in terms of knowledge? What do we have to do to fill that gap? And what kind of research opportunities that we can put out there? So this is kind of breaking news. So this is kind of the first place, I think, I don't know, might be the first place you guys are going to hear it. In the fall, we're actually launching two new RFAs. It's going to come out in September. One is on primary care, and the other is aging and diabetes. So we're really excited about that because people are living longer than ever before with diabetes, and we need the research to match that. And, you know, what Denise was talking about before with primary care, I won't go over that because Denise did a pretty great job, but also ADA has those motivations as well to fill the gaps and more knowledge and research in that area. And right now we have 171 active research grants. We only fund within the United States. So you could be a researcher from another country, but you have to be employed by a university or a nonprofit institution within the U.S. to apply and be eligible for an ADA award. And then, like I also said, because ADA helps everyone with diabetes, regardless of type, so if you have type 1, type 2, gestational, you can apply to us. We don't discriminate against any type of diabetes research. We want it all because that's more shots on goal. All right, so in your packets you'll have more information on this, so please feel free to scan the barcode there. Pathway to Stop Diabetes. So tomorrow after the keynote there is a pathway symposium, and these are the most prestigious award you can get from the American Diabetes Association. We fund a minimum of two per year. We'd love to do more, so hopefully we will this year. But it's a revolutionary goal that we're really aiming to give, you know, early career researchers who are at the peak of their creativity and innovation the ability to be funded, and it's a $1.6 million award, that you have financial freedom. So even if your original project starts out as one thing, but as you're researching it turns into another, that's okay. We want that. So it gives you that flexibility, which not every funding opportunity you see has that. This is why it's very unique and also very prestigious, because we're allowing you to go crazy, you know, and find what's next and what's great. And so tomorrow you'll hear from three of our Pathway awardees, past and present, about what they did with their awards and how it's impacted their career, including Steve Parker, who is getting a very big award, the Outstanding Scientific Achievement Award. He's also a Pathway alumni. So we're very proud of it. The application deadline is July 17th. I encourage you all, please check it out. And obviously if you have questions, you know where to find me. All right. And postdoctoral fellowships. So we noticed prior to last year that applications for our fellowship awards were declining. And we said, okay, what can we do to change this? Because we need to make sure we get more people in the door for diabetes and that people have a place to call home in terms of funding. So this is the second year that ADA is having a loan, a postdoctoral fellowship application pool. I will say last year we funded 30% of the applications that were submitted, which for a funder, that's a pretty high number. So please apply. We encourage it. You know, all aspects of diabetes, we leave it broad in purpose because we really want to see what people have to bring to the table, what kind of mentorship opportunities there are for them. And we want to fund as many as possible. So the deadline to apply is July 23rd. So please feel free to do so. And I highly encourage it. And then last but not least, and you can find more information on the handout you're provided today, on our website, this is where you can find all the current opportunities that we have. So you go to the Research and Grants page. This is on Diabetes Pro, I will say, not diabetes.org. You go to your current funding opportunities, and you go down to this great list over there, and you click on the button, and they'll give you everything you need, eligibility, templates, instructions. There's a lot there for you guys to dig through. You know, grant funding is a lot of fun. There's always instructions to it. And if you have questions, please reach out. You can email us at grantquestions at diabetes.org. Like I said, it's also in your handouts. So thank you very much. Okay. Thank you, Jamie. Okay. Last is Lisa Spain. And Lisa is a program officer in the Division of Diabetes, Endocrinology, and Metabolism at NIDDK. And she's going to give you the NIH perspective, specifically that related to the areas she oversees. Lisa? Yes. Thank you so much. Yeah, as mentioned in the bio, I am a Ph.D. immunologist. I have been at NIDDK for 20 years, and I should be getting my plaque sometime next month. So what I'm here for is to help you get your great ideas funded. As you may know, NIH consists of not just one thing, but 27 institutes and centers. And the reason for this structure is so that NIH funding, which is from the American taxpayer, can go towards both a very specific aspects of very different diseases all across the spectrum. It's an alphabet soup of diseases. But the goal is for overall to improve the health of Americans. And NIDDK, obviously with Dr. Griff Rodgers, is our favorite institute. So what I'm here to talk about today, hopefully, is to help you understand the funder, as my colleagues have also spoken about their funding programs. NIH websites are really easy to use, I think, and you can find the resources, and we're here to help you use the resources. One thing that sets NIH apart, I think, from some of our other funders, is that we rely on you. We are on the same team. Most NIH funding goes to investigator-initiated projects. It's not directed. You can send your application in three times a year. We have receipt dates for most programs. So the take-home messages for today are to contact your program officer. In most cases, you might start with me. That's fine. And don't self-eliminate. Please do contact us. So one important part of it is, how do you know who to call? Like I said, you could contact me, but we also have this wonderful tool. So all the grants that have been funded by NIH are in a wonderful public database called NIH Reporter. And so Matchmaker is a tool that allows you to use keywords and extract from that database all the abstracts from all these funded grants. And so this is really important for you to know about and, you know, to use. So I put in my favorite keywords, type 1 diabetes, autoimmunity, since that's my training and my program. And as you can see, my name comes up and some of my colleagues. So this is a great way for you to find out who you're going to contact. And then the next thing you want to do is to click on the Projects tab on this search field, and then that will allow you to actually read those abstracts. And honestly, it's a really great idea to find out what NIH has funded, and it is a lot. All right, so I'm going to get the panel involved up here a little bit, and then there's going to be time for questions, and we're going to be passing a mic around just like we did before. Although, I'm not sure if the microphones do work, but we're passing the mic around, so we'll leave it there. You know, one thing that I thought about with all four of you in your presentations was the fact that, you know, you're describing the kinds of grants that you deal with, but I don't quite yet understand if I've got a basic science grant, can I get any one of the four of you, or is there an emphasis more in clinical research in one of your organizations versus the other, and what about population science? We're dealing with a world of big data today, and drilling down on big databases is AI driven to a large extent, but complicated, so maybe each one of you could comment about your priorities for funding and where our audience might consider submitting their grant as their priority organization. For sure. So, I think right through to A1D, we've made a lot of progress in type 1 diabetes, as Denise demonstrated. We have moved beyond, well, I don't want to say beyond. We have moved, made so much progress in outcomes, but there's still a lot to be learned, and I think that we do have an emphasis, particularly in the Improving Lives group, so for people with established type 1, moving things along the pipeline towards translational and clinical care and clinical interventions, but there's still so much that we don't know, and I think particularly in our cures portfolio for understanding the autoimmune attack and understanding the underlying mechanisms of type 1 diabetes, particularly for the intention of developing a disease modifying therapy or sustaining a cell therapy in the body, that's where those types of more basic science studies and grants come in. Our Improving Lives group is really emphasizing clinical stage development of therapies and devices. Okay. Thank you. Denise? I would say, so we do all of the basic science, clinical science, as well as implementation science, or as you referred to, population science. Our focus is more on the translational and the clinical work, I would have to accept, but we know that there are gaps in understanding. Our Prevent and Delay portfolio, for example, is dedicated to understanding how this condition develops. It takes a lot of basic science to fund to actually understand, but basic science grows from that, and then it moves up the ladder, and we're happy to be part of your support in some of those phases of your career or how that project goes along. We do care a lot about people with type 1 diabetes actually having access to whatever is invested in the research space. We encourage our grantees, even if it's a basic science project, we say, let's play this forward, this video forward, 10 years later. Where do you want this research to be? We always have an eye towards bringing whatever it is that we're investing in, drug therapy, clinical intervention. What does that mean for people with type 1? How is that going to change their lives? How is that going to impact? Okay. Well, thank you. Jamie, as I departed from board activities as a volunteer at the ADA, the whole research platform was changing quite a bit, and the board felt that we weren't doing enough with patient-related research or more translational research, but the history of the ADA research funding platform has been in strong career development of basic scientists too. Your comment, where's the ADA right now in terms of priorities? Yeah. So, sorry guys, mic problems with me. So in terms of priorities, we really have taken also the early career approach, right? We're investing in the next generation, but also a targeted funding approach. So like the primary care and aging and diabetes areas, those are our two next targeted areas that we want to take the most shots on goal. And in terms of that, and also referring back to your question about AI and big data, they'll actually be components of those two RFAs because we go through a whole iterative process of figuring out what our proposed topic should be, what matters the most right now in the field, and AI and big data actually came out third. So we decided to put it as components and really incorporate it. And in terms of basic translational clinical, we support the whole spectrum of diabetes research. We do have an emphasis on translational. We want things to get into the hands of the patient population. However, we support basic as well. Precision medicine was a priority of ours and it still is, and that's a lot of basic science and of course clinical too. And so we're really excited about where ADA and research are going. And since I've joined and in the last couple of years, there's been a lot of changes to the processes and procedures that we do as well to make it easier for people to apply and also to open up more opportunities for basic, but also translational. For instance, Pathway was formerly one nomination. We opened up that to two per university. One will be a basic bucket and one will be a translational. So now a university doesn't have to pick or choose who submits. Now there's two buckets of funding for you guys. So we're really excited about that being new this year. It was definitely a call, but that's one of the ways we're making changes. All right. Good. Thanks. Ultimately, let's return to the NIH, or NIDDK specifically. I think one point you made that's so critically important is getting in touch with a program officer. I mean, so often you can get really good advice. They're not going to write your grant for you. But if you have an idea you'd like to bounce off them, they'll help you think about that. Maybe more out of the box is how it may relate to what they're funding. And let me just say this. I was privileged to be funded by the NIH for 40 years. And there were many grants that got triaged. And you can take a grant that gets triaged, talk to the program officer, and he or she will not necessarily write your grant for you, but give you advice as to how to revise that grant application and get it funded at the next round. No guarantee. But I'm just saying the program officer is often an ignored person at NIDDK and I'm sure at the other institutes. Lisa? Yeah. Just the other week I had a phone call and someone said, well, I didn't know I was allowed to call you. I'm like, what? You're not allowed to. You're supposed to. Come on. But yeah. We do fund everything. And we rely on you. 70% of the funds that are appropriated by Congress do go to what we call investigator-initiated research. So that means these are your ideas. And so we really rely on the community to generate the next driving force ideas. And for our reviewers, which also are people in this room, to recognize those ideas and to give them fundable scores so we can pay them. We also have... So we rely on you to get those fundable scores. And so that's why I'm in this game with you. I want to help you because if I had nothing that was really good, I would not have a job because there would be no way to get the money out the door. Congress in their infinite wisdom also do sometimes have set-asides, which were required to fund in certain areas, but they usually give us a lot of leeway. And so right now we just had a new appropriation for diabetes research, which is exciting and we're working hard to get that funding out the door for fiscal year 24. So we work hard, but we want to hear from you. We also do initiatives. One thing to know about initiatives is they can seem really attractive. You can think, well, wow, this is what NIDDK really wants to fund, but they can actually be sometimes harder to get because then you've got a call and you've got a lot of applications competing for what can be a limited amount of funding. So really I think the real strength of NIH is it's all about you and your ideas. Maybe just a further comment before we move on to the next question, is the process by which an initiative gets developed, I mean, there's an extramural council that's helpful in that regard. Do you want to describe that process briefly, say an initiative in diabetes-related research in a specific area? Yeah, like, you know, for example, big data, you know, we've had some initiatives in that. So oftentimes our staff gets together, we talk about these initiatives, usually two or three years before the initiative is released, and we'll go to meetings, we'll actually host meetings, we'll have workshops, we'll talk to the community, and then, you know, we will release these. And then a lot of times these initiatives, they will also have sometimes a special funding panel, so we'll get reviewers and it won't necessarily be the standing panel because we'll have some special instructions for reviewers. And make sure you note that before you submit your application. Can I add something? Sure, go ahead. I think part of our job is to understand the larger field and understand kind of the directionality on what is needed and where the gaps are. And so, you know, I was a research scientist, a bench scientist for quite a while, and it ends up becoming, you get too narrowed focus onto what you're doing sometimes as researchers. And part of our jobs is to kind of look at the full field and understand how to kind of elevate your specific research, but kind of twist it in a way that it will have the greatest impact. And I think that's why you should talk to us because you may have all the kernels of the idea, but the framing of it and seeing where it could be in 10 years is how we can help. That sounds like a parting message, but we're not done yet. I just want to add one more thing to it. For our scholars out there, Denise, just a second, but go ahead, then I'm going to post another question. Go ahead. Oh, no, no. I was just going to echo Courtney's. There has been many occasions that the support doesn't come as dollars, but it comes as connections. And Helmsley and Breakthrough T1D, ADA, NIH, we have a lot of connections having been in the space for over a decade with industry, with other researchers that you may or may not know about, or with FDA, with other parties. So we are aware of, we have almost like a bird's eye view of things that are happening that you may not be aware of because you are so focused on this one thing that your idea or your passion or your area. So it is super helpful to, you know, like I said, it doesn't always come in dollars. Okay. Thank you. What I'd like to do now is open up the discussion for the scholars who are in the audience in terms of briefly describing your review process, and then we're going to move to all of you to get questions from the floor. So Courtney, describe, if I submit a grant to the JDRF, what's the review process going forward? So the first step in the review process is internal. Sometimes we use external experts. We talk to our colleagues at Helmsley quite often. Let's think about this project. How can we make, how can we optimize it? Should the emphasis be slightly different? So first at the letter of intent stage, that's where the conversation happens. And we bring in, like Denise said, other colleagues and other investigators to perhaps maybe make the project a little bit more robust. Once we get a finalized understanding of what the project will be, there's a full proposal and our external review, ours in particular is I think pretty extensive. We target a wide panel of experts specific to the project at hand and have an extensive external review. And our reviewers are, we give our reviewers about I think four to six weeks and they take that entire time. And I think one of the assets when you apply to Breakthrough T1D is that oftentimes you get those critiques back even if we are not moving forward. And we find that that allows for revisions and we may sometimes get these proposals back at a later date. So our external review process is fairly extensive. The critiques are I think fabulous. And then, you know, we then sit with this, these critique books. There's a rebuttal process that you will be able to participate in and we make a final. So this is a standing committee and reviewers are selected ad hoc out of that committee? To be honest, it's not a standing committee. We will find the expert that is needed. And sometimes it's a great opportunity to bring people into the community, not type 1 specific, someone who has never touched type 1 diabetes but has, you know, expertise in sensor development in some other space, we'll contact them to find. Okay, let's hear how the Helmsley goes about this. So we have something called a concept page. And that is a key step in our process because, as I mentioned, we're an invitation-only foundation. You don't need an invitation to have a conversation. So it always starts with a conversation. The program officer asks for a concept page about the project that you are willing to pursue and if it fits in our strategy area, if it's addressing a gap that we've identified that we feel strongly about, then we ask for the concept page. After the concept page, there's a lot of back and forth and we have internal conversations and we have discussions about the leadership and if the leadership review goes positive, by the time that we invite you to submit a full proposal, then it's, that is a pretty good place to be. And our success rate after that point of the, you know, it's 99.9%, I would say. That's really important. Like letters of intent up front, then somebody doesn't spend weeks and weeks creating a website. Exactly. We do value your time and we don't want to go, want you to spend hours and hours to fill out a whole detailed, you know, budget and asking, you know, answering a lot of questions, impact questions, building teams together because usually projects require multiple teams to come together. That takes time. So without having the intent to fund, we don't go there. So the discussion, the concept page, going back and forth, understanding what really is the gap that we're addressing is the key. Okay. Thank you. Jamie, the ADA has a committee, correct? So yes. So fun fact here. So JNRF and ADA have the same review process. So this makes this conversation a little bit easier. So Courtney beautifully laid it out. And so, you know, we have the letter of intent phase. If you, you know, and that'll be an internal review, mostly with the chairs of whoever we select for that particular review that are external scientific experts in the field that relate to the research being targeted. And then if you make it to the full proposal stage, what will happen is four to six weeks will give external reviewers, usually three per application. We look high and low for reviewers because we're so broad in terms of what we offer in terms of the targeted research. We go through publications, you name it, to find, make sure we find the right experts to review your proposals because the feedback is the most valuable thing in the world, regardless of you're funded or not. And we want to make sure if you're putting the time and energy to submit to us, and it's a lot of time and energy, and we know that, that you get the feedback in return. And so usually after you're notified of your funding decision, three months after you'll receive your critiques, but blinded, so you don't know who reviewed them, but you'll have all the written feedback. If you want to go elsewhere or if you want to resubmit, now you know, okay, this is what I could change on the proposal. This is what we can improve or do better. Or if you want to take it to other funders to get more funding, even if you were funded by the ADA, now you have another pathway of, here's feedback I got here. What could happen if I applied to the NIH with this? What should I tweak? It's really powerful and impactful, and it's nice that, and you'll find this with a lot of medical research funders, usually the review process is very similar. That's pretty helpful, all in all between submitting an LOI to when you're funded is around like a six-month process, give or take holidays and things in between, but yeah, so that's pretty much it. Lisa, sometimes it's confusing for people in the field to understand the difference between an institute and study sections. Maybe you could help us along that. That's a great question. So at NIH, there's a separation between the funders, which are the institutes, and review, and that's the Center for Scientific Review. So they're completely separate, and there's a firewall, as they say, between people like me, the program officers, and the review process. So when the application comes in, the first thing that happens is the Center for Scientific Review looks at it and decides which one of those 27 institutes and centers it can best go to. And that's why I like you call me first before you submit it so that I can help guide you. We don't want it falling through the cracks, so for example, in diabetes, we don't fund all the research that's done in populations of people with diabetes, because if it's eye disease, then it's going to go to the eye institute, even if the person is suffering for diabetes. So it's all about those outcomes, but it can be a little bit complicated, and you want your research to go to the right fit. You want it to be a really close fit. So that's for the funding decision, because we cannot fund something at NIDDK that's not in our mission. I don't care what the score is. If it gets misassigned, it can't be funded. So that's very important. Center for Scientific Review sort of starts it off, there's some dialogue, and then it gets assigned to a review panel. These are your peers. It's peer review, scientific experts, and they review your application and give it a priority score or a percentile. And then the institutes take it from there. At the end of the day, the decision is after advice from our National Advisory Council, it goes to Dr. Griffin-Rogers, and he approves the final pay plans. So again, three times a year, these applications come in. Just a case in point, let's say you're interested in how diabetes relates to cancer. If cancer's in the title, it goes to the NCI, right? You cannot get anything that's cancer-related or metabolic diseases funded by NIDDK. Am I correct? Not necessarily. That's a great question, because if you have cancer and diabetes, if we're worried about how you're controlling your diabetes, then it can go to us. But if it's all about the cancer, then yeah, NCI. Okay, we're going to open it up with all of you. I know we haven't left a lot of time left, but ultimately, hopefully some questions in the next five minutes can be answered. The microphone will be passed around, right? Oh, no, you're holding the mic, good for you, good. Bring the mic down a little bit. Thank you for your time. Question about if you could describe some common pitfalls new grantees do in applying, and then also maybe once they've received a grant, how people are standout superstar grantees or things that they do that help them be successful once they've gotten the grant. To whom are you directing that question? Everybody? I think everyone. Oh, okay. Be brief. Right. Well, I think, what are the pitfalls? I think first pitfall is not contacting your programming officer. I feel like that's going to be a refrain from all of us. I think making sure you also understand what the goals of the organization are, and make sure you, at the very least, align your proposal or letter of intent to that. And then after the fact, break through T1T, sorry. We meet with all of our investigators on a quarterly basis, and part of that is to make sure to ensure success. We meet with our investigators to discuss progress. We have reporting systems. You'll have to write a report to us every so often, but we meet to help you solve the problems. We don't want you to wallow in being lost. That doesn't help anybody, and so we try to take an active approach in helping you progress. Okay. Thank you, Courtney. Denise? I would say authenticity is a very important trade that we look for in our grantees. We never would want you to tailor your passion area or your interest area to our strategic areas. We would want to know what you feel that it's important and that needs to be addressed, and want to listen to that. So I think authenticity is a very important trade that we look for in our new grantees, and we are always looking for new grantees. That's one of, you know, my job is measured a little bit about how we bring in new projects from new people. So that's, being new is a good thing. So I should not submit. But it's the, also to Courtney's point, I think just blindly sending something doesn't work and it's always, and bringing others into the conversation also. We talked about stakeholders. We talked about exploring the ecosystem to find where you can make an impact. Ultimately, it's never one person in the team. Okay. Thank you. Jamie and Lisa, brief comments, please. So in terms of, you know, being new applicants, and I won't go over what they said, because I totally agree with an ADA, loves new people in the door, and we want that. Don't wait to the last minute, right? We like to procrastinate. We're human. I do it as well. Feel free to contact us, sometimes weeks in advance, so that, A, we can kind of put a face to the name, and then as you have more questions closer to a deadline, you know, we can help you out a little bit more where you're not feeling so frantic and rushed. Also, your Office of Sponsored Research will really appreciate that, too. So shout out to all your universities. And then one of the pitfalls that we see sometimes, researchers that we fund go MIA, and why? Because maybe their project's not going the way they thought it would. And something's not going right. We still wanna know that, good or bad, we wanna know. And it's not being held against you. It's, well, if that's not working, how can we change it up a little bit and figure out something new? Because if that's not working, well, if somebody else is applying to us with that idea, we now know from your research, maybe that's not something we should be funding because X, Y, Z, they did this way and it didn't work out. So my brief two cents there, but feel free to reach out with questions if you have more. One thing that I'd like to say is, as a new investigator, don't give up. I looked at my portfolio and I looked at all those applications that were ND, not discussed. You have no chance of getting funded if you're not even getting discussed. And it turned out that if none of those people resubmitted, I would lose half the grants in my portfolio. Now, this is from new investigators, established investigators, it's different. But for new investigators, it's important that you not give up. Yeah, that is really critically important. So is there any other burning question from the floor? I'm sure our panels will be available right after this. If not, I'm gonna ask for a one sentence words of wisdom from each one of you to our scholars who are out here today. Corky, one sentence. I can't steal this last one, don't give up. Thank you. Yeah. Denise? Explore the parts of the ecosystem and find where you can make an impact. Very nice. Yeah, the weirder, the better. So come with your innovative kooky ideas, come on down and apply, because it could be something great. We should talk privately about that one. Lisa, final comment. Yeah, how can I top that? Except to say, please call us. All right, let's thank the panelists for a great discussion. Thank you. Now you can meet Betsy Sequist, who was up here before. So hello everyone. So my name is Dr. Daisy Duan, and I am a member of the ADA's Early Career Advisory Group. I'm currently an assistant professor of endocrinology at Johns Hopkins. And I have been involved with the ADA since I was a first year endocrinology fellow sitting in your seats back in 2018. And I previously participated, actually, in this specific program. It used to be called Focus on Fellows. And I found this to be incredibly helpful for career development, and also very inspiring to hear about all these established researchers and clinicians. So I am currently an NIH-funded physician scientist studying the intersection between sleep and circadian biology and metabolism. Speaking to the last session, actually, I did contact Dr. Lisa Spain before my K23, and she was very helpful. And I also serve as the associate program director for our endocrinology fellowship at Hopkins. It's my absolute delight to moderate and introduce the next session, which is on mentorship. It's a topic that's very close to my heart because I really could not imagine navigating through the academic career without my mentor's guidance. So it's now my pleasure to introduce our speaker, Dr. Elizabeth Sequest. She is the Nesbitt chair of the Department of Medicine at the University of Minnesota Medical School. She also serves as the associate dean for medical specialties and primary care, and the co-director of the Institute of Diabetes, Obesity, and Metabolism, improving the lives of people with diabetes through research and clinical practice, and training the next generation of investigators in the areas of diabetes, endocrinology, and metabolism have been her professional goals for the past three decades. She has directly supported the career development of more than 55 students, residents, fellows, and junior faculty over the course of her career. She also served as the president of medicine and science of the ADA in 2014. For her work in research and mentorship, she has been recognized by the ADA with the inaugural Lois Jovanovich Transformative Women and Diabetes Award in 2019, and the Albert Reynolds Award for Outstanding Mentorship in 2020. So I'm gonna welcome Dr. Sequest here. Thank you, Daisy. Can everyone hear me okay? I know that I also am vertically challenged, so I can just see over the top here. It'll be great. Thank you for the introduction. Thank you for the invitation to come and talk about mentoring. I almost don't even know what to say because there's so much to talk about with mentoring, but I will go ahead and get started. Let's make sure I'm doing the right thing here. There we go, all right. So Mentoring, Nurturing, Growth, and Development is the title. The objectives will be to understand the role of mentoring, to explore the benefits of mentoring, and to learn how to establish effective mentoring relationships. So really, what is mentoring? I think we kind of all know, but let's just have a definition so we can all be on the same page. It's a professional relationship in which an experienced person, presumably that's your mentor, supports and guides another person, the mentee, in personal and professional development. And the origin really comes back from the Greeks. Odysseus left for the Trojan War and placed his friend Mentor in charge of his son. And the Mentor was an experienced elder, a counselor, and a teacher. And so that's really, mentors are entrusted with the care and development of their mentees. So what types of mentoring do we have? There's a lot of types of mentoring. I think when we talk about this, we often really narrow in on formal mentoring where we have assigned mentors and mentees. We do that in our programs. That is critically important and I'll spend a lot of time talking about that today. But there also is informal mentoring, the relationships that develop naturally based on shared interests and mutual respect that can be very valuable. These can be peer mentoring or it could be something a little bit different. There's group mentoring, and some of our schools are experimenting with this a little bit differently because we do not have enough mentors in the mid-level to mentor all of the junior people. And so there might be one mentor with multiple mentees where they meet together. And as a group, they foster collaboration and peer learning. And then there's peer mentoring, which is really important. Mentoring among colleagues at similar levels, usually for support and guidance in a non-hierarchical framework. There's a lot of concern about how do we control for the hierarchy in a mentoring-mentee relationship, and we'll talk a little bit about that. So the question is, what are the benefits of mentoring to the mentee? What do you hope to get out of that relationship? Right, so. So the big one is guidance. Everyone wants guidance. I want guidance. We all want that. Networking, career development, experience, knowledge, a little bit of wisdom. I think that's all true. And this is what I think about is the benefits of mentoring to a mentee. Guidance, I thought as well. This is me as a mentee. This was a long time ago. Expanded networks, increasing the confidence, and exposing someone to career advancement opportunities. I think those are all, those are some of the benefits that you can get, a mentee can get from their mentor. What are the qualities of a good mentor? All right, more answers. Look at that. So the big one, I'm waiting to see, available. Available is really important, isn't it? Availability, responsiveness, patience. Lots of non-judgmental, easily approachable. There's a whole lot of qualities that are listed here, more than the benefits that people thought that mentees would get. You hit many of them, but there are some things to look for, I think, when you're looking for a good member, a mentor. A mentor has to have empathy, really has to understand and relate to the mentee's experiences, challenges, and emotions. So this is particularly important that you find someone who you think can do that. A mentor actually has to actively listen, has to be fully engaged, genuinely interested, and provide thoughtful responses. A mentor has to be patient, because you have to give the mentee time to learn and grow at their own pace without judging them. You have to provide guidance, offering direction and resources, and you have to support, to provide encouragement and advocate for the mentee, both in front of the mentee, with the mentee there, advocate for them and support them, but away from them as well. And what are the benefits to the mentor for this? This is a big relationship, and I think people start becoming mentors because they like to help others. It's a very nice thing to be able to share what you've learned in the hard way, so someone else doesn't have to learn it that way. For many people, it's leadership development. They learn how to provide leadership to groups. If they do some of this, they get better in communication skills, especially in places where they actually have training for mentors, where the mentors are trained on how to do this. I've always found it's great to get fresh perspectives on how you approach problems, and obviously science itself, new perspectives of that. And don't forget that mentorship helps the mentor. Most people cannot be promoted in this country to the level of full professor if they have not participated in mentoring and training programs, so that's a real payoff for them. They need to do this, and they better be good at it if they're gonna do it. So I think the characteristics of an effective mentoring relationship really is to have mutual respect and trust. Both parties have to feel comfortable expressing thoughts, ideas, and concerns. You have to value each other's perspectives and experiences. You have to be nonjudgmental, and you have to be confidential. So how do you establish a mentoring relationship? Well, often mentors and mentees are assigned to each other, and then they formally meet to assess the mentee's goals and the mentor's capabilities to ensure compatibility and alignment of goals. It's helpful to establish goals and expectations at the outset, setting objectives, timelines, and methods of communication between the two. And it helps, I think, to make a contract with each other so that you can increase the accountability of the relationship. And I'm sharing with you some things we developed in Minnesota for our T32 program. We've applied it with K programs and all of this other stuff, too. But we require our fellows, our mentees, to actually sign an agreement if they're going to start a new relationship with a mentor. And we say what their expectations are. So they have to work with their mentor to develop their career goals. They have to identify strategies that will facilitate objective achievement. They have to identify how research experiences and training will be acquired. They have to develop an annual timeline that shows how they're going to do their training. In this program, we asked everyone to have a grant submission. That may or may not be part of your agreement. We asked fellows or trainees to establish regularly scheduled meeting times and to attend them, to show up and be there. In this program, we had to tell them how many hours a week we expected them to be working, what sort of meetings we expected them to go to, and what sort of presentations they would be expected to do during the course of a year. No surprises for the fellow then. This is what the expectations are. And so they know how can you accomplish something if you don't know what is expected of you. We also have the mentors sign an agreement. And the mentors are expected to assist the fellow to develop his or her goals and objectives, to help identify what strategies will facilitate objective achievement, identify how these research experiences and training will be acquired, develop the annual timeline, and help them with their grant submission. The mentor has to agree to establish regularly scheduled meeting times with the person to review progress. We have to make certain the person is actually coming to work. That's one of the things we had learned we had to define. And we had to personally, the mentor has to go to the same meetings and research presentations as the mentees. You can't just sort of blow by and not go. You have to both go because that's how you establish rapport and learn what people need. And then we have them work in their first encounter with each other, and maybe it's more than the first time, on a annual statement of goals and objectives. And we'll come back to this at the end if we have time and have each of you work on filling this out. And I'll come back to that when we get there. So how do you sustain a mentoring relationship? These are often long-term relationships. And I think some of the things that are important, if you, once you set expectations for how you're gonna act with each other, like the schedule, stick to it. Don't change it. It really is very hard to actually interact with each other if you never follow through on your schedule. Go ahead and address any challenges. If you're feeling uncomfortable about something, about the relationship with your mentor, bring it up. They're a grownup. They should be able to hear criticism and figure out how you can work better together. The mentee, the mentor has to address any challenges the mentee has in achieving goals. Sometimes setting a timeline isn't enough to mean the work gets done at the defined time. Sometimes you need to, there's some extra work that needs to go into that. And you will have to address any challenges the mentor has in providing good mentorship. If there's something wrong with the mentor, again, we both have to talk about how this is going and make certain that we are doing what we plan to do from the outset. And if it's not working, then we need to go and have someone either help us establish a better relationship or help you find a different mentor or mentee. It's really important to provide constructive, honest feedback. That's very important. Saying, good job, really nice. That's probably not very helpful for anybody. You really need specific constructive feedback. It's helpful to identify areas in which both could improve. And it's important to celebrate achievements. This is exciting. People do great things and we need to recognize that and celebrate it. And in academia specifically, how do you sustain a mentoring relationship? I think one thing that's really critical is to remember this is about you. You do not have to imitate your mentor. You do not have to grow up to be just like your mentor. Be true to yourself. And it's fine, but you have to grow up to be yourself. And if your mentor is trying to make you in their own image, they're probably not talking to you enough about what your view of yourself is. I would say, just like call the program officer, never submit any grant or paper without a full review by your mentor. Be sure you give them time to do that. It's really important that things that go out the door with your name on it are as polished and as good as they can be. So that means you have to give yourself time. Ask a lot of questions and plan ahead. Plan ahead so you can get timely feedback. And sometimes what I will actually do with mentees is what's your goal? You wanna accomplish this? We will back up in the calendar and say, you need to start last week if you're gonna accomplish that. And we have to make sure that they understand the time it takes to do things. We all need multiple mentors. An assistant professor can have a research mentor and usually does, who is an expert in the field of study and may have a career mentor, someone else in their department, who helps the mentee understand the promotional guidelines and how to be successful in the culture of your academic environment. If you're on a career development award or a K, particularly a K award, but it could be any career development award, now they often will have a bio stats or a bioinformatics mentor as well to help you with that aspect because it's so critical to anyone's research project. So if we have a mentor, does this all work? I wanted to present a little data. Being a scientist, I like to see, does this all really work if we follow the rules and everything goes the way it's supposed to? This is a nice paper. It's a little old now. 2019 is pre-pandemic, but these authors examine the outcomes of people who submitted K awards between 1990 and 2016. And they looked at those who did and did not get the K awards and they adjusted for variables about the person. And these are people who are right at the payline. If you were like an outlier, they weren't in here. These are people, we all know it seems kind of arbitrary and sometimes it kind of is. So they wanted to compare people who just missed it with people who got it. And then they did a regression discontinuity design to control for variables. And you can see the inputs, they controlled for qualifying degrees, the field of study, race, ethnicity, and gender, the age at which the K was put in, any prior support, and then the program characteristics, the mechanistic goals, the institute priorities, the number of K applications, institute budgets, looked at the activity. And then what their output is, how many people got an R01 or an R01-like award, how many got multiple awards over the time. Did the team who got the grant, but also most importantly for this purpose, was given a mentoring team existing of at least two, probably three or more people. Did they do better at progressing to an R01? And they did. This is looking at all of the people, all of the awardees, no matter what their award was, and the percent of K awardees who had the first R01 equivalent compared to the control 24 times more people had that, or the same for the R01s. And it really mattered for the K23, the clinical awards, the people who were given that mentoring team to do a clinical project were much more successful in getting the next grant. And so I think this is some evidence that mentoring may be a really good thing in helping you move forward in getting subsequent grants. Another study just is to look at what is the career trajectory, and this is, they call it an elite cohort of US basic life science postdoctoral fellows, and the influence of their mentor citation record. When I was a mentee very early in my career, I was so intimidated by everybody, I only wanted to talk to people who would be nice to me, which was not the people who published a lot. I was just, and was that a good idea, or should you really go out of your way to find someone who has a great publication record? So these are people who got F32s during their postdocs, 92 to 94, and then it's, and the people who they could track going forward. So the men are on the top, the women are on the bottom, what we have is the fraction is on the y-axis, and the people who got no grant, who got a major grant are the bars. And each of those groups are, the shaded colors have to do with the mentor's citation record, or number of publications. And so the one with the biggest citation record is way over on the right, the ones that are hatched. The dark black ones are ones who have less publications. So for men, it really didn't make any difference how much the mentor published, the ones that went forward and got a grant. The women are on the bottom. And what's interesting is that publication record of the mentor was significantly associated with a greater likelihood for women in getting a subsequent grant. And so you can interpret that many ways. It may have to do that men will, I'm gonna be biased here, men will blow through whatever barriers there are. Women sometimes, myself for sure, needed a mentor to help me meet people to go forward and get the networking necessary so that I could be in that ecosystem that we heard about and be successful. So what has my journey been as a mentee? Well, early in my research career, I had a local mentor with expertise in my area of research and career development, Fred Goetz, a landmark person. They didn't used to do kidney transplants in people with diabetes, it was a contraindication. Can you believe that? He was really the one with the team in Minnesota responsible for making that become a more commonplace thing. Wonderful guy. And then Paul Robertson, who Bob knows very well as well, was my mentor during fellowship. Fred is now gone, but I went to his funeral and had a relationship with him really my entire life. Paul and I still talk and he sends me his book. And so we used to have these relationships for life. But over the years, as I've gotten more experienced, I've relied more and more on peer mentors to help me. And they really helped me with reality checks on what is, is this a good idea or is this not? And here is a picture of some of my peer mentors from the University of Minnesota at a past ADA meeting. And what has my journey been as a mentor? I couldn't remember how many I mentored, so I said more than 25, but it probably is more than 50. I put some of the people here who I had pictures of. The things that I've really learned is the importance of listening and really understanding the mentee's goal. They aren't being made in my image. They're being made to be successful people in their own right. That requires really listening because I don't know what they're thinking unless they tell me. And you have to recognize that goals change over the life of a mentor-mentee relationship. Lisa Chow is now the division director. She's my boss now. I'm in the division of endocrinology. She's my division director. I met her as a medical student. She came to Minnesota to do her K with me, and obviously things have changed over time. I still rely on her for her good advice, and I share some of my thoughts with her as well. It's been a good relationship. So I'll stop there for questions, and if we have time at the end, we can go forward with the activity. I know that sometimes your mentor can be not what you hoped, can you help to guide us through what to do about that? So did everyone hear the question, what if your mentor is not what you hoped? Well, I think it's important first of all to recognize that you are in a mentor-mentee relationship within a culture of an academic institution. So even if it seems like the mentor is all-powerful, that mentor has a boss, and there are things that we have to hold accountable. I would first, it depends what the issue is, of course, but I think it's the mentee needs to be sure to spell out what their expectations are at the beginning. The mentor needs to agree that those expectations are something I can help you with, so that everyone's on the same page. If they do that, hopefully they won't end up with something, but we know sometimes best intentions don't seem to happen. Someone is too busy for you, being available was something all of you talked about. I think it's probably better to work on the relationship and be very honest about what the shortcomings are before you just jump ship. I would engage your division director or your program director, whatever, wherever you are in the level, to let them know about this. Many times a mentee, even when they're junior faculty, feel very nervous about telling someone something like, you're not doing what I need you to do, and I'm going to go find someone else. It's sometimes helpful to have someone else help you with that discussion, and the division director or program director would like to know that as well, because we need to make certain we're providing good mentors for people. I would call it out and talk about that. Another thing, if I can just expand, you didn't ask this, but I've thought about this a little bit as well. One of the things that people will often talk about is when things aren't working, is when people's personal life experience is very different. There used to be a big discussion when I was a fellow a million years ago, that can men serve as mentors for women, and there weren't very many women, so what were we going to do? We were going to do what required people talk about the issues that as a woman I face that my mentor would not even think about, and talk about it. That's true whenever there is any discordance between background. Something that has to be accommodated, thought about, managed in some way that is unique to that person, we need to address that and be sure that we all understand what's going on. Yeah, go ahead. Right here. Yeah, go ahead. Yeah. Hi. So my question is, how should one approach for mentorship? Is there a good way to, and what makes a mentor more amenable to accept someone as their mentee? What is the right way to go about it? Well, in our department, every single new hire has a mentor. It's required that they are assigned a mentor, and that's part of the annual review process of the mentor, that they are doing the mentoring that they were supposed to do. So that's one way to do it, and I think it's, at least it gets things started. We actually have another whole team who then monitors the mentors and mentees a couple times a year to be sure they're doing what they're supposed to do. It's kind of an elaborate process, but it's been pretty successful. If you're not in a place where people assign you mentors, or say you're going in a whole different direction and you want to do something, ask someone. I mean, I think you can think about, what do you want from my mentor, and make a list very concretely for yourself, share it with this person, and see if they will do that. That's one way. Another way is to do the same list sort of thing and talk to a senior person who you trust and say, I know I need a mentor. I'm thinking of this person, this person, this is what I need. Can you connect me? Sometimes it's hard to do things, to cold call people. Everyone usually will answer the phone or at least open the door and talk to you, even if it seems like they won't, but they will. I have a comment, slash, I think others on the panel can comment on this. I think one fallacy people have is that they only have one mentor, and what I found helpful in my career so far is that no one's perfect. Sometimes you'll find a mentor that they're great for the research, but maybe they're not so great with the broader career or the work-life balance, or they don't have the same background, and so you need someone that could relate to you in that sense. I think, I guess, one of my rules is, one, I never get rid of my mentor. Once a mentor, always a mentor, and so I'm very proactive of keeping the mentors I have from when I was in residency or medical school, because I think at different points in life, you can pull on those people, and they can be very helpful. And then two, if there's a problem or if there's an area maybe my mentor is not the greatest at trying to find someone that could address that issue, which is maybe having young kids and starting a career or navigating some, being a clinician and investigator or whatever the case may be. I don't know if everyone else has that. I agree completely. I think everybody who is hired as faculty wants to be promoted, and that requires you have knowledge of your promotional guidelines, and usually that means someone within your own academic unit. But that person may not know anything about your research, and so you need more than one mentor for sure. Yeah. And I think speaking of that, there's also people discussing roles for sponsors versus mentors. Can you speak to that? Tell me what you mean. I've heard people talk about that sponsors are typically people who are more, these are people typically like division chairs or department chairs, and so they can sort of connect you with other people or provide you with bigger opportunities, but may not be doing the day-to-day. I need to submit this. How do I write a cover letter? They may not have time or availability to do that, but I think if your expectation is that person is going to do that for me, then there could be a mismatch, but really they're there for you on a bigger role in terms of introducing you to other people. Yeah. I think that's very... I mean, I would hope that every division director and department chair feels that they should be a sponsor for every one of their faculty. I mean, we only look good if our faculty look good, right? So it's to our advantage. But I do think, I mean, there are people in my department who meet with me, assistant professors meet with me as department chair once or twice a year just to keep me in the loop with what they're doing. And then there's others who I have never talked to and never reach out. All of them have mentors. They have different needs, but I do think it is not unreasonable to reach out so people know you. I think that's important. Other questions? Please feel free. Otherwise... Yeah. In that kind of multiple mentor frame, I think a lot of us know how to start the conversation and identify a research mentor, but how do you start the conversation from that career mentor and define that kind of role? I think it starts with you deciding what do you want to accomplish. And presumably, it's that you want to be successful in your academic unit and be promoted, for instance. I mean, that's our measure of success. So you probably want someone who is knowledgeable about this, has probably gone up for promotion already, and is willing to spend the time with you doing that. And I think that also piggybacking on that, I think if you, for example, if there's other career paths, I think you guys had a session on career paths earlier today, there's another career path that you're interested in or at least interested in exploring. You can find that person in your division. Because within a division, there might be different people with focus on different things and you can speak to them about their career paths, et cetera. And so there may be somebody who is a little bit more clinically oriented, for example, if that's the type of career you're interested in. I think it's thinking about, at least as a fellow, it's thinking about what do I want my career to kind of look like or what are the options I'm exploring and see who kind of has that. And that might be a good starting point as well. Other questions? And then I think, because I think a lot of the questions... Yeah, we prepared some questions, but you guys have asked a lot of similar ones. I think, well, I guess let's start with one of the first ones. When do you think for a fellow? When do you think is a good time to start looking for a mentor in their career? When you apply for fellowship. You should be looking at the faculty who are there. And hopefully there's someone who looks like they want to do... You would like to know more about. I think you... And always, I mean, you need to have someone to help guide you along the way. And then how does one go about selecting the right mentor for them? Yeah. Again, I think you have to know what you want and what the goal is. Based something on the data, I would go... I would look at someone who's experienced and networked into the field. I do think that's helpful. I wouldn't have done that when I was younger. It was too scary at first. But it's really important and I urge everyone to do that. Go to national meetings with this person and they'll introduce you to everyone. Very important. But you need to know what you want. If you are a physician scientist and you want to get a K08 and be in the laboratory, you need someone who really knows your area of research really well so that they can help criticize the projects you're developing and help you move that along. If you are a clinical scientist, probably you need the same sort of things. I'm a researcher who does this kind of work. I think once we start blurring the line between clinician and researcher, it gets a little bit muddier. And it's because, are they really a clinician? Are they an investigator? How do you manage the time? And I think it depends on where you want your career to go. If you are planning for a research intensive career, then you need a research mentor. If you're planning for a clinically focused career with some academic time to do things, it's probably best to have someone who has successfully navigated that very difficult path to help you with that. Should we go to the activity? Yeah. All right. I was struck when I first started mentoring how few people were able to actually write their objectives in a way that was something they could measure and be held accountable for. So if you go in your packets, there is a piece of paper that is the, I'll show it sort of to you. It looks, it's much better formatted than this. This is me, the person who did it, did it better formatting. But I think it would be helpful at your tables if each of you wanted to establish one career objective. Something you want to accomplish this next year. What is it you want to accomplish? What strategies are you going to use to achieve that goal? When will you start and finish that particular strategy? And how will you know if you've been successful in achieving the goal? Is that clear to everyone? Do you need an example? Okay, an example. So my objective is to submit a R01 application. And I would like to do that this year. Strategies to achieve that goal will be, one, writing a specific aims page, which means I need to have developed the project in my head. And there's all of these stages about how you write that. That strat, I'll start it right away and finish it. One thing I would do in my university to accomplish that would be to enroll in a grant writing course that will move me through that whole process so that at the end I will have a measurable grant. Could be all sorts of things. So we'll spend a couple minutes and then we'll have people who are brave, they can read out what they decided, what they wrote down. All right, everyone. So I think first we'll give you guys the opportunity to maybe share amongst, like within your table, amongst yourself, share what you, if you feel comfortable, and kind of share what you've written for your objectives. And we'll give you guys about five minutes to do that before we kind of reconvene as a group. So anyone would like to maybe volunteer what their objectives are and share? Yeah, we have the mics. That's right. Or just sharing what has this experience been like, you know, sort of writing things down and thinking through your plans. I think I was just talking about, I think it's not myself, but someone else said really nicely their objectives look like it's balanced. They have a career goal, I just thought that was wonderful. Maybe I should put that down. Right. Like practice habits, and like being a part of wellness, also in terms of efficiency, things like that. And then it's really nice, like Pearl, too, I talked about how writing a script is like an off-site, it's a lot of work, and that is research, and I'll definitely share that, like scheduling appointments with myself to make that happen, to be really comfortable in terms of actually doing the work. Great. Also, I think what you just shared is an example of peer mentorship. Right, where you're learning from your colleagues because we often face the same challenges in the same career stage. Thank you so much for sharing. Anyone else you'd like to share? Or have any questions about mentorship? I think they're ready for a break. Yeah, that's right. They've been sitting a lot, all morning, quick lunch. All right, thank you guys so much. Thank you. My name is Estelle Everett. I am an adult endocrinologist and a health services researcher at UCLA, and I'm the moderator for this session. A little bit about my background, so as I mentioned, I'm a health services researcher. My focus is on approaches to improve care, the way we deliver care to patients' populations who historically have poor outcomes with diabetes and have a particular interest in type 1 and also leveraging diabetes technology to prove outcomes in these populations. I am also NIDDK K23 awardee and have a clinical trial looking at technology use in at-risk populations. Within the ADA, I have a few roles. I'm on the membership advisory group and the health care delivery and quality improvement interest group. Similar to Dr. Duan, I did this one. It was called Focus on Fellows twice, I believe, as a resident and as a fellow, and so I really commend everyone for being proactive and being involved in these career development programs because I think the skills and the knowledge that you learn through these programs really will significantly impact your career moving forward. Our next session, Negotiating Contracts, I think is a critical topic and something not often taught to us in our medical training or scientific training at all, but is really relevant no matter what field you go into, whether it's academia or private practice or industry, early career and later in life, this is an important topic, and so now I have a pleasure of introducing our speaker. Dr. Bryn Marks is a pediatric endocrinologist, clinician scientist, and director of technology of the Diabetes Center at Children's Hospital of Philadelphia. Dr. Marks attended the Sidney Kimmel Medical College at Thomas Jefferson University, completed her pediatric endocrinology fellowship at Boston Children's. During her fellowship, she developed an interest in medical education and pursued a master's in health science professions education from MGH Institute of Health Professions. Her experiences living with type 1 diabetes for over 30 years has shaped her research interests, which center on promoting equal access to diabetes technology and developing innovative approaches to diabetes technology education for clinicians and youth and families. She serves on the ISPAD Advisory Council Chairs, the ISPAD Education Committee, and is a member of the ADA Scientific and Medical Programs Oversight Committee and the Type 1 Diabetes Exchange External Research Advisory Group. So we look forward to your talk and hearing what you have to say about teaching us about negotiation. All right, Dr. Marks. Thank you so much, Estelle, for the wonderful introduction. Hope everyone's still awake. Hope you got some coffee. And I hope this is useful with apologies in advance to anyone that's heard this before because my approaches to contract negotiations have not changed in the last year. All right, so here we go. These are my disclosures, none of which should be terribly relevant for today. These, however, are relevant. So I'm not an expert. I don't have a law degree. I don't have an MBA. But I have successfully negotiated contracts for two pediatric clinical research positions successfully as italicized because I'm going to share some of the stories that I've been through along the way. You can decide how successful I was. And my real bias here is that I am a pediatrician and I'm also a clinical researcher. So please don't ask me about bench research. I don't even know what a pipette is. The other important thing to make note of here is that even though I'm not an expert, I have talked to people that are experts. I've talked to some lawyers. I've talked to some MBAs. I've talked to other people that have negotiated. So hopefully this will be useful no matter what background it is that you have and where you're looking to go in the future. So objectives. I'd like to start off by understanding the value of contract negotiations to examine the principles of negotiation and then to develop a framework to help you negotiate your best possible offer as you look for that first job. And we are going to go ahead and we're going to start it off with a poll. All right, here we go. So the question is, how do you feel about negotiating? Which emoji best represents you? Awesome. All right. So I will tell you I did this in the past without the fancy slide and I got a lot more people that said they like negotiating so I think the anonymity here is helpful. So we have 3% of people who said they really like negotiating. Congratulations to all one of you. We had about 50% who thought that negotiating made them want to vomit and then about half who kind of fell in the middle. Thank you so much. So as we think about this, why does it matter? Why are we negotiating? So the biggest thing to keep in mind, you're negotiating to get yourself to a better position than you would have been in had you not negotiated. It's important, right? If you're not going to do it, you're not benefiting yourself. You've all been through a lot of training. You know, at least three years of residency, three, maybe four years of fellowship. If you're one of those med-peds, gluttons, you've been through a lot of training. There is a need for endocrinologists to be recognized for that. So don't forget about that as you think about next steps. So a little bit more about me. I did my fellowship in Boston. And during that time, I came in thinking I was going to be a clinician. Ended up falling in love with medical education and realizing that there could be research in that area. So as I did that, I got a Master's in Health Science Professions education but came out with no funding because I found this passion a little bit too late. So as I was looking for my first job, honestly, most of my interviews were for clinical positions. And so I went to this interview in Washington, D.C., and they said, do you want a clinical position or a research position? So ended up with several offers that I was excited about. But really, there was one that I wanted. It was that research position. And that fact that I had a single offer to do research really had a huge impact on my first negotiation. The other thing worth noting here, I was interviewing for these jobs about a year ahead of time. So kind of, I was a little bit on the early side doing it end of summer of my second year. So do keep in mind, it takes some time to go through this, especially if you're looking for research support from an institution. So I spent about three years in Washington. During that time, I was working on developing a K23. But pretty quickly realized that even though it was a nice start for me, it was not sort of the institution that I was looking for. And so again, about a year ahead of time, I started looking at other opportunities. And I was actually at a conference in Montana with my now mentor, hiking down a mountain with her children when she proceeded to pass away. And she proceeded to pick me off and sort of say, hey Brynn, do you want to come home? Because I am from Philadelphia. So I started talking with her and actually ended up looking at several other positions. So this time around, it was a little bit different because I had multiple offers. And that too, impacted my negotiations because I had multiple offers that I was excited about. So ultimately, I settled on Philadelphia. We invented this title, the Director of Technology of the Diabetes Center. That was something I negotiated with my chief, didn't exist before, but it was sort of a promise and I'll tell you more about that as we keep going. So the framework for my talk is based on this idea of principled negotiation. Can't take credit for this, but it comes out of the Harvard Negotiation Project, and if you're looking for a quick book review to give you a little bit more background, I would recommend this one, Getting to Yes. And there's four principles that we're going to work through in more detail, but the gist of this sort of approach to negotiation recognizes that the more you know, the more you know about what you want, about what your future employer wants, the better the conversations you can have and the better the negotiations can be. So as we start talking through this, let's start off by the idea of separating the people from the problem. And I'm going to take full pediatric privileges here and slate a Disney movie in my talk. So here we go. Anyone who has not seen the movie Turning Red, it features a 13-year-old Canadian-Chinese young woman who suffers from this terrible hereditary curse where any time she has a strong emotion, she turns into a giant red panda. Certainly it's a bit exaggerated, but I think based on the reactions that we saw from the room, I'm going to bet that many people have this happen to them, myself included. So just recognizing the emotions involved. It's stressful trying to negotiate. It's also stressful for your future employer, right? They probably have a position that they want to fill. And recognizing the way you're thinking about this from your perspective versus the way that your future employer is thinking about this and just being cognizant of that in how you're communicating. Just to give you an example, I have a nurse practitioner on my research team. We work very well together, but we communicate incredibly differently. So Seema jokes that she's learned to speak British over time, and that's something you may not have the benefit of when you're negotiating with someone, so just recognize this. Recognize that no one is out to get you. They are looking to get something done. You're looking to get something done. And just take a minute to pause and to understand that. And one example that I'm going to use a couple of times throughout the talk, I feel like I'm working with so many of my fellows I've heard that they get asked to go to a satellite clinic that they don't really want to go to. Maybe it's a far one. So you're thinking, that's a heck of a commute. I don't want to go out there. Your chief is thinking, I've been needing someone to fill this position for a long time. I can't bug the senior people. And you can sort of see how this could be a tense situation. So the next principle that we're going to get into is to focus on interests and not positions. I am a big fan of doing your homework. And the reason for that, the more you know, the more that your potential employer knows about you, the better your conversation is going to be. And so there's different ways to think about this, right? There's institutional needs. What does the institution need? Do they need someone to go to that satellite? Do they need an expert in diabetes technology? Do they need an adrenal expert? Do they need someone to run the fellowship program? And then the other piece of this course is something I'm going to guess you have all thought a bit about. What does the market look like? So I'm going to break this down for both pediatrics and internal medicine. And what you're looking at here, this is data from the American Board of Pediatrics, looking at the number of pediatric endocrinologists by state around the country. So if you look, you will notice that there are concentrations of us in certain locations. And yet there are deserts. If anyone would like to join that one colleague in Wyoming, I'm sure they would be desperately grateful. But don't just think about the number, also think about the density, right? So even though there's only seven in Washington, D.C., that is the most densely populated location for endocrinologists. So think about where it is that you're looking to go. Think about what the need is. And recognize that even though there are more densely populated locations, we are struggling to fill our match positions. So the number of positions offered in pediatric endocrinology has declined over time from about 108 in 2020 down to 120 in 2024. And you'll notice we only filled 60 of those positions, which says to you that there is an unmet need. Very few applicants aren't matching. The other thing I'll tell you is that more senior folks are retiring. We've lost people to industry, especially during the pandemic. Many, many places have been recruiting for a long time and there are unfilled positions. And here's the money shot. Get your cameras out. You're going to want this. So this is the AAMC Faculty Salary Report. So what they do, once a year, they survey accredited medical schools, and the medical schools will respond sort of indicating the salaries according to academic rank for their full-time clinicians. And what you can see here, according to academic rank, you'll see 25th, 75th, 75th, and mean. And the data that's in bold is from 2023. It's the most recent report we have right now. Below in italics is what happened in 2022. So I did want to give you a little bit of hope, show you that the salaries are getting better over time. And just keep this in mind, because I would love to make a million dollars a year, but I am pretty sure if I ask my chief for that, it's not going anywhere. So you've got to know what's reasonable. You've got to do your benchmarking. In this report, they actually used to break it down by geographic region. So to put this bluntly, the cost of living in Ohio is a bit different than the cost of living in Stanford. So they're no longer reporting out that data, but don't forget to factor in cost of living when you're thinking about this. All right. We are going to switch over for the medicine folks out there. Apologies that I don't have identical data to share with you. I couldn't find it from the ABIM. But this is a publication from 2015 that looked at where internal medicine endocrinologists were working in 2012. So here, the yellow dots show you where it is that adult endocrinologists are working. And you'll note that they are heavily concentrated in cities, about 97, 98% of them are located there. And then the other thing to keep in mind is the shading on the states. And what you can see there is just the population density. And here, you can identify that even though there are more adult endocrinologists than pediatric, there are many parts of the country that are still lacking. Data here aren't quite as disappointing as they are in pediatrics. We're actually seeing a slight increase in the number of positions over time. So it went from 305 filled positions in 2020 up to 350, which is great. We've actually seen increases in the number of applicants, unlike pediatrics. So whatever you guys are doing in medicine, I'm going to argue some of it might be the two years. I'm going to argue some of it might be salary, because the pediatricians are more fun. But whatever it is, we're seeing more applicants, which is a great thing. But don't be deterred by this. Even though there are more applicants over time, still not enough. And here is the data for adult internal medicine endocrinologists. So same exact data that you're looking at here. And apologies in advance to the pediatricians who have made note that the average salary difference is roughly $40,000 a year. Not my fault. Sorry. All right. So circling back, you've done your homework. You are sort of thinking about the emotions involved. The next step of this is the idea of inventing options for mutual gain. So as much as I would love a toilet made out of solid gold in my office, I thought about negotiating for it and quickly realized it would not benefit anyone besides me and maybe my fellows if I let them use it. So the real thing to think about here, what are you trying to achieve? What is the person you're negotiating with trying to achieve, and how can you use that to work together? Right? So going back to this idea of having to go to a satellite that you don't want to go to, your chief needs that position filled. You need a job. But there might be other ways to sort of think a little bit more creatively about this. And this is often referred to as the idea of expanding the pie. So it's not, yes, chief, I will drive the two hours to that satellite three times a week or no, chief, I won't do it. But maybe it's thinking creatively. Maybe you have a colleague who has an interest in the patient population there. Maybe you have a colleague who actually lives closer to that satellite. And so the more you get to know people, the more you understand the area that you're working in, the more you can think creatively and think about finding a solution. And then the last principle of principled negotiation is this idea of insisting on objective criteria. Hopefully this isn't a foreign concept to anyone. I like to liken it to the smart goals that we often set with our patients and families. And the idea that whatever it is that you're talking about, it should be specific, it should be measurable, achievable, realistic, and timely. So just make sure that the things you're asking for, that you're clear. It's not I want more money, it's I would like to be paid at the 75th percentile because the cost of living here is very expensive. Maybe it's the number of sessions a week that you're thinking about with your chief. Why do I have to do two more than everyone else? So be objective about it and do that research. The other thing I will tell you, having negotiated for a couple of positions, it is a very, very small world in endocrinology. In fact, people that I have negotiated with offers that I ultimately didn't take. I now sit on boards with some of these people. And I am very glad that I was nice to them and that it ended amicably because I see them all the time. And in fact, Estelle and I were just laughing because we were on an ill-fated research project that has not been funded yet and never thought we'd run into each other and here we are. A couple of other things outside of the principles of negotiation, just to be mindful of, there are power imbalances, right? I remember this feeling coming out of fellowship. I am that little guy in the diaper going up against a major academic institution that has done this many times before, that has lawyers backing them. And the thing to keep in mind here is how do you protect yourself in the setting of power imbalances? And the term BATNA really comes up here. And this is the idea of the best alternative to the negotiated agreement. So to make this a little bit more concrete, when you're negotiating, the last thing you want to do is end up in a worse position than you would have been if you didn't negotiate. And here you have to think carefully about the situation. So I told you my very first job, I had one offer to do a research position, everything else was clinical. I did not have much leverage in my negotiations. My chief knew I wanted that research job. I knew I wanted that research job. So I was a little bit more cautious in the things that I asked for. And yet, when I came to my second negotiation, I had many opportunities that I was incredibly excited about. And really, it let me do a couple of things. One, it let me compare the offers, the things that I didn't even negotiate for, just what was standard from one institution to the next. And two, because I could have been happy in multiple positions, I was able to push a little bit harder because I knew if my top choice didn't work out, I had a pretty good plan And the first time I went in to negotiate, I was convinced I was going to nail the interview. It was going to go perfectly. My chief was going to say, Bryn, we have to hire you right here on the spot. And we were going to do everything right then and there, mano a mano, talking through offers and the things that we needed. But the reality, I learned quickly about something called a wish list. So the way that I've seen contract negotiations work, I've typically gotten an offer letter. This is something that's a little bit easier for your chief and your division to secure. There's certain things that will be on there. But before you go and you formally sign that contract, they want the contract when you get to that phase to be ready to sign because it's often going up the next level. It might be going to the chair. So as you get that first offer, this is really your chance to negotiate. And the way that you're going to do it is to respond in writing. So what you've got to do, take a look at what they're offering. And then literally sit down and think about what are the things that I need to do. And in terms of thinking about what to put on that list, I'm going to borrow a quote from Stan Musial, who was one of the greatest home run hitters of all time. And he said that the first principle of contract negotiation is don't remind them what you did in the past. Tell them what you're going to do in the future. And to put this a little more concretely, I'm going to tell you about what I negotiated for in my most recent job. She likes to refer to herself as a line item, but I like to tell the story of negotiating for a human. Her name is Seema, and she is a nurse practitioner on my research team. And what I realized in making the move from Washington to Philadelphia, I knew the things that I wanted to do. I wanted to get involved in research studies. I needed to be up and running quickly with a K23, and I knew I couldn't do that without the right team. So Seema and I had worked together pretty closely for about three years. I also knew that I needed about half time effort for this nurse practitioner. I knew that Seema wanted about half time research, about 0.3 clinical. And so I spent six weeks going back and forth with my chief to get Seema. And I am so thankful that I did, because with Seema there to work closely with me, I've been incredibly productive. And the way that I got Seema was that I told the chief that that was what I needed. And I think she quickly realized that. It was still a big ask at the time. I think she's forgiven me for it finally. But I think seeing how well things have gone in the last few years, I think she understands why I asked for it now. Other things to think about on this wish list. I think the first and foremost thing that's going to pop into everyone's mind is this idea of salary, signing bonuses, moving bonuses. My experience is at least I have had limited success in negotiating the amount. So what you get offered, it's often based on the ranks of people above you. You can't get paid more than your colleagues. It's a little sticky situation based on the location, based on the hospital, based on your effort. Are you research or are you clinical? Sometimes there's differences in the salaries. Same for signing bonuses, same for moving expenses. So don't hesitate to think about it. Don't hesitate to ask. But specifically at my institution, they said this is the offer. There is no negotiating. You're happy with it. You can negotiate over other things or you can move on. So what I would encourage you to do is think outside the box. Contract negotiations don't begin and end with money. So seemingly silly things, office space. So we have a tight situation at CHOP. Some of our offices are about a 20 minute walk away, which is less than ideal when you're a clinical researcher. So one of the things that I had to think about was where was my office going to be? Are you the kind of person who needs an office? Are you going to work at multiple different satellites? Does it matter to you? Academic appointment. So there are certain institutions out there that believe in the instructor role. Good luck negotiating with that in your first offer. There's not much you can do. And I see chuckles. I, too, had the offer to be paid in Harvard dollars as an instructor. But keep in mind, as time moves on, you may have that negotiation. Right. So when I made the move, I might have been considered an instructor at CHOP, but really pushed hard to get to that assistant professor level. And sometimes it's a nice way to kind of jump the academic ranks as you move, which also comes along with salary incentives. Don't forget to think about non-clinical time. Full-time clinic can be pretty busy. And I think I saw from the intake survey, it looks like about half of you guys are thinking clinical positions in the future. How many sessions a week is that? I've seen somewhere at six. I've seen somewhere it's nine. What are the things that you can do that might protect you a little bit from clinical time? Some of the examples we've talked about before. Is it quality improvement? Is it fellowship education? What are the things that are going to fill your bucket that are going to help to decrease some of the workload with patient care? What about the ability to work remotely? Different institutions have different policies on this. So I'm very lucky in that if I don't have to be on site, my employer could care less where I am. Others are really still insisting on full-time in-person work. If you're full-time clinical, it may not matter to you, but if you're research, it may be something worth thinking about. The other thing I've put on here is this idea of a non-compete clause. So what this is, is if you were ever to leave a position, sometimes there is a one-year clause saying you can't work within a 30-mile radius of any of this particular institution's centers. And where that factors in, when I was in Washington, I know if I left Washington, I was not going to any other hospital in Washington. So for me, it didn't matter. But now that I'm home, where my family is located, that 30-mile radius becomes a big deal. And what I've highlighted for you here, just in the last year, the AAMC supported some legislation really trying to ban these non-compete clauses because they recognize that it's tricky to be forced out of a city. There is a clause in there that sort of leaves the ability to use a non-compete clause in place for senior executives. I certainly am not treated like a senior executive. I hope I'm not considered one in case this ever comes up. But there is sort of a little bit of wiggle room in there, although certainly the trend is really trying to get rid of these non-compete clauses. Other things to think about benefits, administrative time. Again, we were talking about clinical sessions. How much effort do you get in terms of time to call your patients back after visits? We are a pretty heavy lab specialty. There's a lot of work to be done in between visits. What about your academic stipend? It's really nice to be here at Focus, well, what was formerly Focus on Fellows, now ADA Scholars. You get your registration covered. You get a couple of nights in the hotel, but all of a sudden registration goes up when you are in attending. You've got to pay for that hotel. So thinking about how much money are you getting so that you can get to a conference, maybe cover some of your publication costs and worth asking about that. The last thing on here I almost didn't even include because they're unlikely to be negotiable. But don't forget to think about other benefits, retirement, disability, all of your health care insurance and maybe tuition benefit. That may be something that you're thinking about if you are looking to pursue another degree. To get a little bit more specific, I'm going to do my best to help the research folks here and then we'll go clinical. I shared my story with you about people, right? I think people as a clinical researcher are probably the biggest things that you need. So whether that's a research coordinator, a manager, is it a clinical person like a nurse practitioner or someone who can do a pump start for you? And don't forget about statisticians. I've been at three institutions now. They are hard to come by. In fact, my institution right now, even though I'm based at CHOP, the statistician is based at Penn, which increases the costs of working with him. So don't forget to ask about how you're going to get access to a statistician. What about funding and duration? So the initial support that I had when I moved to CHOP, they told me it was going to go away in three years. And I said, well, that's that's a little tricky because I'm coming in with a K. And with that K, I'm not going to need this now, but there is probably a rainy day where you will need it. So worth thinking about with your chief. Can I extend the amount of support that I get here? Don't forget about supplies. You know, if you're if you're a basic science researcher, you can talk to Brittany about these things. But don't forget to think about lab costs, about space in the lab, about the tools that you need, about freezer space. If you're a clinical researcher, where are you going to do your study visits? Are you going to have to pay to use the clinical research center? Can you maybe get your chief to let you do them for free in the clinic? And don't forget about publication costs. I'm consistently horrified every time I publish the amount of money that it costs me. And yet you've got to do it. So don't forget to think about these things. What about for the clinicians? So I'm not going to beat a dead horse. We've talked about clinic locations. So keep that in the back of your head and see if that's something you can get in writing in terms of where you'll be asked to go, just so that you're not spread all over the place. We talked about templates, too. How many sessions a week are you expected to do? What does that look like? Are your diabetes and your endocrine separate? Are they built in together? How much time do you get for a new patient? How much time you get for a follow up? In fact, I am spoiled because I get extra time with my diabetes patients, which I love because there's so much educational work to be done. Personnel also become important on the clinical side. Do you have good M.A. support? Are you taking blood pressures as patients get checked in or are you going to have nice vitals there ready for you? What about nursing? Are you going to come into a huge basket of messages at the end of the day because your patients need refills, because they have questions, because they need help with something? Or do you have an excellent nursing team, maybe diabetes educators as well, that are helping patients to do that and just coming to you for help as they need it? We've talked about protected time as well. So thinking about things you can do to get yourself a little bit of time outside of clinic. And then the last thing this was really talking to one of my clinical colleagues recently, it was this idea of RVU targets. So this is basically how much money you are expected to bring in every year varies tremendously from one institution to the next. And are there goals that you need to meet? Will you be held responsible if your patients no show? I am. That's frustrating. I'm in clinic waiting to see them. And if my patients don't come, that counts against me, which is hard. And then if you are expected to hit certain targets, are they realistic? Do they factor into your bonus structure? Right. Again, like I said, it's not my fault if my patients don't come unless I'm mean and terrible to them, which I try not to be. But thinking about that and how it impacts your bonus. And here's where that idea of your actual salary is something that's guaranteed to you versus a bonus. Things that may be out of your control really becomes important. So we're getting towards the end and really now you're going to learn from my mistakes. So important things to remember. First and foremost, you're valuable. You are highly trained. You guys are all sitting here in this room. So I'm going to guarantee you we've got the creme de la creme. Don't forget that. You know, we come from a match process where you're just feeling lucky to have made it to the next level. And now you are fully trained. You're ready to go. You're valuable. You're going to be great. Don't forget it. The other thing that may sound silly, but the perfect job doesn't exist when you're looking at them. I had a couple of my my attendings tell me the grass is always greener on the other side. I was so eager to make moves. And then you get there and you realize there's limitations to everything. Certainly certain things I know when I signed my current job, I wasn't thrilled about them. But on the whole, the benefits outweigh the cons. Another thing that one of my mentors said to me is you're not going to be able to another thing that one of my mentors said to me is your first job won't be your last. I was so convinced I was looking so hard. I wanted it to be the perfect job. And it didn't make sense to me as I was signing my contract. But a couple of years in, when I was saying this isn't right, I'm not happy here. Having that voice in the back of my head to say, you're not tied to this. You can look for other options. You can negotiate again. The other piece I'll tell you is that neither of the jobs that I've taken were actually posted. So the first was sort of connections through my fellowship training program. The second, I am not sure what got into my mentor's mind and what made her decide that I needed to come to CHOP, but I'm grateful that it happened. And somehow after these conversations started is when the actual jobs got posted. So what you're doing here today in this room, getting to know people, networking, is just so important in the next phases. Next thing, if you don't ask, you're never gonna know. I know it is intimidating to be asking for things to be negotiating, but if you don't ask, no one's gonna advocate for you. They're gonna be happy to give you that base offer that they made. So don't forget, it's worth a shot. Make sure it's a reasonable ask, but ask, because otherwise you won't find out. And then the other story I'll share with you, I was sort of telling you about that first contract negotiation that I had where I had one research position and a couple of clinical ones. I remember going to my chief and I said, hey, the salary at this clinical location in a very rural location is, oh, you know, $60,000, $70,000 more a year than yours. And he literally laughed at me, it was totally fair. And he said, fine, take it. I said, oh, okay, all right, we're good. But again, the more similar position offers you have, the more you're excited about multiple ones, the better you have to negotiate. And the last piece of advice is really lean on your mentors here. I still have one of my mentors, yes, I have mentors seven years out, who I call every time I look at a contract. It still makes me a little bit nervous, even though I'm up here on this stage. Talked to her last month as I was looking at a consulting agreement, and I always learn a little bit of something. So I think the more comparing and contrasting that you can do, someone's always got a little more experience than you. Someone's always got something to share. So don't be afraid to ask. Your mentors are here for life. You're stuck with us. Sonya, I'm talking to you. And last but not least, conclusions. So just keeping in mind, practice these principles of negotiations. Share information, do your homework, think carefully about the emotions, and use all that information to have a good, productive conversation with your chief or whoever it is that you're negotiating with, so that you can really create specific, mutually beneficial solutions. And just remember, it's hard to hire people. There aren't enough of us. Your chief wants you to stay, and they want you to be happy. It's hard to replace people. It costs a lot of money to do it, and just keep that in your mind. I think I've said this a couple times now, but hopefully you've gotten the message that you are valuable, and you should dream big when you create your wishlist. And then last but not least, protect yourself. Know your walkaway point, know your alternatives. And that is the end of it. All right, thank you for that excellent presentation. I think you definitely gave us some gems in there, and things that everyone should consider. One thing, well, I guess a couple things, a comment and then a question. So as I'm looking in the audience and seeing a lot of women, I remember when I was a fellow, there was a talk that I went to, and there was like this glaring stat of like women are much less likely to negotiate than men, and that could be one of the contributors to like the salary gaps. And so that was something that was always in my mind. And although it's like uncomfortable, I remember like, I'm not gonna be one of those people. And then, you know, that, you know, and so I think that's something that always stuck in my mind. And I think some of these strategies are really helpful to kind of give you that push. One question that I have, and I'm gonna go off script, but I'm sure you'll have a great answer for this, is that, although I didn't stay at the institution that I trained at, I strongly consider, I actually thought I would. And I think it's tricky when you're staying at your institution where you train, because one, they see you as a trainee, as a fellow, and then also if they know you wanna stay, that kind of gives them some leverage. And so I think it's kind of, it's more tricky to negotiate when you're trying to stay versus trying to go. Because I think there's a leverage that kind of gets lost and you're maybe a little undervalued. So what suggestions do you have for people who want to stay at their home institution? Oh, such a good point, Estelle. I could not agree with you more. I think if you know and you let your institution know that you wanna stay, they're not gonna work too hard to keep you. They know. So what I would say, play it a little bit coy. Don't be too honest in saying that I desperately wanna stay. And then honestly go out and interview. The job offers that are out there, what a job looks like at different institutions, it's so radically different. It's different than fellowship where you have this prescribed curriculum that you have to get through. Honestly, you owe it to yourself to go out and to look. I'll also tell you that it's a tremendous way to network. Even one of my mentors told me, even though you're not seriously considering this job, you should go and give a talk there because you want them to know what you're up to. So do that, get those offers. And I think that's when you may get a little bit more leverage, although I make no guarantees. So I definitely took that approach and interviewed at different places. But interestingly, like when you interview other places, then you really kind of get a better sense of your value. And then you're like, oh, wow, they are like very impressed with me. Oh, I actually, and it kind of empowers you a little bit. But you also may get an offer that you're like, oh wait, I'm actually leaving. So that's what happened to me. And even my chief, I remember went back and he was like, oh, this is actually a great offer. We can't even do this here. So you should probably go. And so, but you just never know what's out there. And I, so even if you're determined to stay, I think always keeping your options open is helpful. Great point. Thank you. My next question. Let's see. No pressure. We can take questions from the audience. Oh, actually, yeah. Let's see if anyone in the audience has, oh, we have several. Let's come up to the mic. Thanks for the fantastic talk, Ian. I recently signed a contract, but it was so good to really hear your viewpoints. And I think I agree with a lot of those. Now, during the interview process, and you mentioned this, endocrinology is a really small world. When you end up having more than the expected number of interviews, then you have to decline some of those. What are your tips on how to not burn bridges with those people? Because these are people you might have to come across again and I think from a collaborative atmosphere of work, I would love to probably do something in the future with them. Any thoughts? Yeah, thanks so much for that point. There may come a point where you have too many interviews. So the first thing I'll say, if you've got a reasonable number of offers and there is something you know you're not gonna accept, it's okay to decline. I tend to be honest. I had some offers to go to locations that I just had no desire to move to. And I said, hey, I have a lot of respect for you in your institution, but I would like to stay closer to my family. So passing on that, you could come up with a mentor story that you have an established relationship. So I think there's ways, and I believe in being honest with all of this, ways to be truthful and yet say, I appreciate the offer, but it's just not for me. So just be cautious as you do it and don't abuse, don't go to too many. I'll also say something someone's told to me is that don't tell someone, if you're considering an option, but you have other, don't say, oh, I really wanna take this. Don't give the impression that you're going to accept an offer and then pull out last minute. I've heard from many people that leaves a really bad taste in those institutions mind and they will always remember that. And so I think just being genuine, if you're considering other options, they should know that you're considering other options. And so just be genuine and don't falsely lead people. Thanks, and the other thing I'll add is that as you're getting close, as you're locking things in, things can fall through. Certainly during the pandemic, we saw that where there were financial crises, people that thought they had offers kind of lost them. So what I would say, buy yourself some time, don't officially decline until you've signed on the dotted line. But to Estelle's point, be honest as well, don't mislead. Thank you so much for this session. As someone who's watching other people go through their process and starting to do so myself, I had two questions. One was when people say we do not negotiate, but in fact, they do eventually, like when to, like I've seen that happen multiple times with my friends, like how to read out the, like, is it ironclad we do not negotiate or I think everyone does kind of, anyways, that's one of my questions. And then my second is when you have multiple offers, I have seen them use time as a constraint in terms of you must accept my offer with an X amount of time. And I'm sure they have their reasons, but it's difficult when you're kind of considering multiple options with different timelines in terms of acceptance and how to deal with that. Yeah, great point. So let me take the timeline question first. I was actually in an interesting position. The first job offer I had, the deadline I was given was the end of August. I hadn't even finished all the interviews that I intended and I very naively fell into that. It was the research position, so I was happy with it, but those deadlines are often soft. So there is nothing wrong in saying I need a little bit more time. I'm looking at other opportunities. I have a significant other who's also trying to find a job. And honestly, I've not seen people hold hard to those. If they are trying to do so, they may be trying to take advantage of you. So really just do your best to ask for a little bit more time. And then the second piece, the negotiability of the salary offers. So I've gone kind of one for two. My current institution, they held fast. There was no negotiations with the first one around. I really used that AAMC salary. So I literally went in, I said, hey, this is a really expensive area to live. This is the 75th percentile. If I'm gonna live here, if you're serious about wanting me, I need to be able to support myself. So I think just being honest with that, being realistic. I don't know, I think it's gonna be so variable from one institution to the next. I think it's gonna depend on how many things you're pushing on. So certainly you wanna ask, but you can't ask for everything. So what I would say, make sure that other things, if you're getting no, no, no, no, no, make sure that you're happy with the other parts of the offer that you have before you try pushing really hard on that. And I don't know if you have other experiences with that one. Yeah, I think I agree. I think someone told me that this phrase and outside of negotiation, but I find helpful, like let them say no. So like, it doesn't hurt to ask. And then if they can't, they can't. But also certain institutions like the UC system, there are certain things that are like ironclad that can't be negotiated, but there's also like ways around it. Like the base salary has to be the same, but people get like quarterly bonuses that are like guaranteed. And it says in your contract, you get 50 extra thousand dollars every quarter for the extent of this contract. So there's ways around it. And so I think just because, I think there's always some area you negotiate in. And if it's not money, as you mentioned, you had several slides of different other aspects to negotiate, there's something, there's always a way to negotiate. And so I wouldn't let the first pass, no kind of deter you from trying. So I think a question, this is, I think we have one. Oh, we have one. Sorry. Yeah. Oh, she was coming up. Oh, no, come to the mic. So I had questions about private practice. I think we've talked a lot about academia, but are there places that we can find salary data, RVU expectations, even in academia? What is, you made the comment about, what is the best way to negotiate What is, you made the comment about, is the RVU target appropriate? How do we know what a good RVU target is? And how can we compare that RVU target to like salary, especially when you're looking in the private practice setting? I was worried somebody was going to ask me this, and this is why I get to give my disclosures up front. We don't really have private practice in PEDS. And then I'm also going to admit that I am full on a researcher, but I was actually, I was talking to a colleague who's getting ready to give this talk for the fellows at her institution. She's also a pediatrician, and she was trying to pull other pediatricians around the country to see what their RVU targets were. These don't mean anything to me, but what she told me, they vary from anywhere to 2,200 a year to upwards of 4,000. So that I think is really tricky. It seems that there's a tremendous amount of variation. So I think the more people that you know in that position, honestly, make friends, especially it's got to be in that area. I'll tell you, we've had people interviewing at CHOP recently, and after I get to know them, they have asked me salary. And I think that's completely reasonable. I think the more that we're honest and upfront about this, the more that we can protect ourselves from getting taken advantage of. And what's so hard is I think private practice, it's going to depend where you're looking. It's going to depend what the role looks like. It's going to depend, are you going in with a potential partnership role? Are you going in as an employee? But the more people in that similar position that you can pull, there are a lot of Facebook groups out there. There's an endocrinologist one that I kind of quietly stalk. There are many private practice endocrinologists on there. And I know there are people that are really out there that are looking to help you and to share that information in a way better than I can. So I'm sorry, I don't have a better answer for you. What's the endocrinology Facebook group? I'm going to find it for you afterwards. Come find me. I'll go first. So I had a question about the difference between a research and a clinical endocrine job when you're doing this negotiation process. And the AAMC salaries seem like they're just generalized to endocrine. And often it seems to me when you're coming in as a just graduating fellow, you may not have secured your own independent funding. You're asking for an institution to support you. How do you approach that with the salaries that are kind of average? And it seems like at least my observations have been that researchers get paid less than clinicians. And any insight you have on that would be fantastic. Yeah, absolutely. And when I was finishing up fellowship, that was clearly the expectation. In a very expensive city, the researchers were going to get paid far less than the clinicians. And the justification was, well, the clinicians are bringing in all the SRBs. They're bringing in money to the division. And I think as a researcher, when you see the indirect costs that are coming in as a result of your grants, when you're speaking at a meeting and people are hearing, oh, chop, like you're doing a lot to bring your institution in as well. I did not have any success. That was why I did not end up staying in Boston when I had the chance to. I just didn't work around it. And I think what's so tricky, some of that is just embedded. It's just sort of the expectation. So I don't know if you have any better advice. I didn't do very well there. I think, so in terms of kind of understanding like what is like an appropriate salary for a researcher, I just spoke, I just asked a lot of people to go around the different country to see like what was the starting rate. And then obviously that will vary based on the city. I'm in Los Angeles, it's a very high cost of living. So that's going to be quite different than if I was in Baltimore or somewhere else. And so I just asked a lot of people to go around to get a sense. And then also if you have different people look at their contract, and ideally like senior people, like if you can have, they kind of get a sense of what is like appropriate. or not. And then I think you can expect to be like less than the clinicians, but I don't know, you can kind of get a sense whether that difference is extreme or not. I think one important thing, I guess kind of adjacent to this, topic for those who are researchers and are trying to secure a research job, it's really important to take a look at your contract in terms of, is what they're offering me a situation that will allow me to be successful? Because I had a recent colleague who was supposed to come in as a researcher, and his clinical schedule was not conducive to trying to write a K and get funded. And so I think taking a look at your clinical time is extremely important and that should be something you can negotiate for, probably even more important than money if you're really trying to establish yourself as a researcher. And then infrastructure in terms of space and personnel and help, admin help is like, oh gosh, if you can negotiate for that, that's probably better than money for sure. And so I think thinking about those aspects of mentorship and things of that sort are really, really important and something you should really focus on. Because if you have an institution that offers you a lot of money and you want to be a researcher, but the infrastructure is not there, it may not be the best job. So I just thought I should mention that as a researcher. The other financial hope for the research folks out there is as you get more established, you get chances to speak at places. There are often fees that come along with that. So you may have a chance to make it up on the back end, even if it's not as part of your salary. And I'm a strong advocate for NIH, NLP, the loan repayment. That makes a huge difference. And so if you can get your loans paid off, it definitely helps balance things out a bit. I'm not sure how we're doing on time. Okay, good. Hi, I'm Dale. Thanks for your talk. My first question is, for those of us who already have a job and have signed a contract, when would be a reasonable timeframe to start a conversation for renegotiation of our contracts? And how do you go about starting that conversation? Interesting question. So my experience so far has always been employment at will. You sign the contract and then you're kind of there and you're stuck and there's no end term to it. So something really that I would sort of ask around with your colleagues in terms of how that works. For me, I've never had the chance to renegotiate. I had all the power up front when they were trying to lure me in and then haven't been able to renegotiate since. But oftentimes there are annual increases. So usually like a 3% salary increase per year comes up and I am happy. I don't know if you've had the chance. So I came in, I was very lucky to get a research position with no funding. And so they gave me a certain amount of years of protective time to get a grant. And I got my K, I think, before that time. And then also I was trying to buy a house in California, which is hard. And my mentor was like, oh, when you get a grant, you should renegotiate, especially because you got it early. So they're saving them money. And so I was able to negotiate. Although I will say, I didn't really have to push for it because I happen to have really good and supportive chiefs that were very open to that and were like, oh yeah, you got your K, we'll give you more money. And so it wasn't that hard of a negotiation. But my mentor, who I hear is a master negotiator, she's like, every time you get a grant, you should negotiate for more money. I just got one. So we'll see when I get a R, how a couple R's, how that works. So we have five minutes left. Any other questions from the audience? Yeah, sorry. So I was just going to, it's not really so much of a question, not really much to do with contract negotiation, but it kind of struck me during your presentation on the picture of the US and the shortage of both pediatric endocrinologists and endocrinologists at large. And I think we're inundated, at least in training, of what salaries different medical specialties are making. And endocrinology usually just falls on the lower side of the spectrum. And I'm just curious as to, just by principles of supply and demand, how our compensation ends up always being on the lower side. And if there's anything as a specialty or a field that we could do to sort of advocate for ourselves. I wish it was as simple as supply and demand. I think it's more about RVUs and unfortunately being a relatively low billing specialty without many procedures. I think that's sort of where that justification comes from, that we end up paying more. I agree with you. I think it's something that we certainly need to work with. We certainly need to lure more people into endocrinology because we're seeing rising rates of obesity. We're seeing increasing rates of diabetes. And we need people there to take care of it. I know there are sort of discussions happening behind the scenes. I know that there's a lot of interest in why we're not feeling good in pediatric training positions. And that's been part of the conversation. But I think starting that conversation, I think talking to leadership positions, whether it's Pediatric Endocrine Society, and really getting the ear of people because you're right, it's got to be a collective effort to think about how to reshape that. All right. Well, thanks so much, guys. I'll be around. I'm going to hang out for the reception. So if you have questions you didn't want to ask in front of the group, happy to help. Thanks. I'm Bhargavi Patham. I'm an Associate Professor of Endocrinology and Clinical Medicine at Houston Methodist Hospital. And I'm also the Director of Clinical Integrative Programs at the School of Engineering Medicine at Texas A&M University. It is my distinct pleasure to welcome Dr. Michelle Lichman, who is an Associate Professor and Nurse Practitioner at the University of Utah College of Nursing. She serves as a Medical Director of Intensive Diabetes Education and Support Program at University of Utah, a multidisciplinary diabetes self-management education and support program. Her NIH Foundation-funded program of research is the Nexus Between Diabetes, Digital Health, and Health Disparities. Her research has three overarching foci, technology-mediated diabetes interventions to address health disparities with emphasis on deaf, Hispanic, and rural communities, the social context of diabetes management in online and family environments, and novel methods to examine real-world diabetes self-management. Her research on access of diabetes care has been highlighted across national media outlets, including NPR, Science Friday, CNN, and The Doctors. The Language of Care is a short documentary highlighting her work where deaf community premiered in 2023 Sundance Film Festival. Dr. Lichman has worked closely with legislatures and national professional organizations where her research has influenced policies and practice. She has received a research doctorate and master's from the University of Utah and undergraduate degree from Weber State University. Dr. Lichman is a Jonas Scholar, Betty Irene Moore Nurse Leader and Innovation Fellow, and University of Utah Presidential Society Impact Scholar. She has been inducted as a fellow of American Association of Nurse Practitioner, Association of Diabetes Care and Education Specialist, and American Academy of Nursing. She's a co-chair of ADA Health Disparities Committees. It's my distinct pleasure. Please welcome Dr. Lichman. Thank you so much for having me. I appreciate the invitation. So we're going to talk about health disparities with a lens of diabetes care. And I just want to start out by saying that I'm the daughter of a deaf immigrant mother. And not only is my mom deaf, but so are five of her siblings. So I have six deaf family members in total. And what this has done is it has helped me see the lens through the deaf perspective and how they approach the health system and how they don't have ASL interpreters always at their appointments. And what happens when you don't have an ASL interpreter? When you think about people with diabetes, we know that about one in nine individuals live with diabetes. And that is threefold for people who are deaf. And so there's several reasons why we think this might be. So the first concept is dinner table syndrome. So if you think about the last meal that you had with your family or even friends, perhaps it was last night, you're all sitting around at a table and you're interacting with one another. You're chatting. But what happens is deaf people, 90 to 95% of the time, they have a hearing parent. So automatically there's two languages and they don't know each other's, right? And then 70% of those hearing parents never learn sign language. So imagine your parent never talking to you. That's the experience that a lot of deaf people have. And so this concept of dinner table syndrome is everyone's sitting at a table, interacting, and there's one person who gets left out, that deaf individual. And there's a lot of information that happens in bypass. Oh, grandma had a hip replacement or so-and-so has diabetes. So there's a lack of information that doesn't get passed on to you secondhand because you don't have that language. The next thing is a lack of ASL interpreters. So the statistic is 50% of the time when a deaf person requests an interpreter, it's not provided, even though we have the American Disabilities Act that requires one be there. And then if someone shows up, an ASL interpreter, about a third of the time they're actually not qualified to interpret medical situations. A lot of us don't realize that interpreters, while they do have to be certified to be interpreters, they may not be qualified for a medical situation. There's actually been lawsuits where an interpreter went into a legal space and interpreted legal jargon inappropriately, and it changed the case. And so imagine if you have an interpreter in the room who doesn't know the difference on how to sign hypoglycemia or hyperglycemia. Those sound very similar, but they mean different things. And so having a qualified interpreter is key. So one thing that you may not know if you haven't worked with an interpreter is you've got this deaf person with diabetes on the left-hand side. They're signing to a hearing American Sign Language interpreter who then voices to a clinician like a nurse practitioner, and then it goes back and forth. One thing that a lot of clinicians don't realize is there's actually a second type of interpreter called a certified deaf interpreter. A CDI is actually someone who is deaf, so now you've got a hearing interpreter and now you've got a deaf interpreter. And the reason for that deaf interpreter is ASL and English are so different, and when you're taking in information ... Has anyone ever seen an ASL interpreter? Like maybe on ... Yeah, so you've seen it happen. What happens with, let's just say Spanish, is someone speaks English, then they stop, and then someone speaks Spanish, and then they stop, and then it goes back and forth. If you've seen a sign language interpreter, they're listening and signing at the same time about 10 seconds behind. So what happens is you can miss information or you can sign things literally like signed English, but that's not how deaf people sign. They sign in American Sign Language, which is a different language. So then you've got this certified deaf interpreter who can actually take that information and expand the knowledge, create a way that a deaf person can actually better understand that. The other is ASL is not visual English, so sometimes if we can't communicate with someone, we're just going to give them a handout. And so this happens often is you can't communicate your needs to a deaf person, so you just print out some instructions and hand it to them. But unless a deaf person is bilingual and knows ASL and English, that written handout does nothing. It would be like handing someone who speaks French a handout in Spanish. It does nothing, right? And so you have to make sure that you have language congruency with the patient education materials that you have. We do have a significant population that are monolingual ASL users only that don't know English. The other is a lack of video-based education in American Sign Language. So we did an analysis of YouTube, which is where a lot of videos live, and we looked at deaf, we looked at ASL, diabetes education, we looked up a lot of different keywords, and we found that there were only 20 diabetes education videos in American Sign Language that existed. And 11 of them were assignments by ASL interpreter students. So now you've only got nine videos, and most of them were just very basic. So knowing that diabetes is something, you know, what diabetes is, but not really how to manage it. And so there's a lack of information actually in their language. So let me just frame this talk about talking a little bit about social determinants of health. Have you guys heard of social determinants of health? So this will just be a quick review for some of you and maybe new for others. But SDOH, or social determinants of health, are non-medical factors that influence health outcomes. So if you think about education access, this is where you can think about literacy, language access, so schooling in your language. Interpreters in schools is a situation that deaf people sometimes have and sometimes do not have. Access to a deaf and hard of hearing institution. So we do have deaf schools, but they're not located in every single area. My mom, when she went to school, she actually had to live in a dorm and couldn't see her parents because it was so far for her. Also vocational training and higher education. So then there's healthcare access. So if you think about a deaf person, it's healthcare coverage, provider availability. Your provider is linguistically and culturally competent. They actually understand deaf culture. They know sign language. You actually have interpreters that are available, show up, and they're qualified. And then that quality of care. The neighborhood and built environment. We think about housing, transportation, access to healthy food, safety, parks, playgrounds, walkability, and zip code. And then the social and community context is really that sense of belonging, absence of discrimination, and absence of racism. And then economic stability. So employment, income, food and security expenses, debt, and medical bills. So I'm going to talk through a little bit of a diabetes education program I run, and then we'll come back to these S2H factors. So I'm a clinician researcher, and so I like to fuse my research and my practice together. So in 2017, I was asked to develop the Intensive Diabetes Education and Support Program. This was funded by the previous owner of the Utah Jazz and their family because Larry H. Miller had diabetes and the wife wanted to fund diabetes. And so we did a one-time eight-hour boot camp type education program, and we had an NP dietician and social worker. And then I was able to get funding through NIH to really adapt this program for rural context. So we did it virtually in the primary care practices in eastern Colorado, and we added a pharmacist. This was done in both English and in Spanish. And then I received a fellowship to really adapt this ideas program for the deaf culture context. So there's phase one where we actually design the intervention. We do that adaptation. We had to engage a deaf community advisory board in order to do this. Because even though I understand deaf culture and I'm part of it, the disability community has a saying, nothing about us without us. And so really making sure that we're including people in that design. Then we did a participatory trial and got feedback. So before I talk about the research that I did, I want to share this documentary. It really highlights the diabetes community advisory board that are deaf of all across the country. So they're from Maryland, Texas, Wisconsin, California. They're all over the place. So let me share this video with you. I will never know what it's like to be deaf, but I do know what it's like to be hospitalized. And it's a scary place to be. My aunt who is deaf was hospitalized for an infection and asked for an interpreter. And she was told she could only have one when the doctor did his rounds. One day she was having difficulty breathing and the nurse didn't understand this sign right here. When they denied my aunt that interpreter, she never had a chance. When I found out that my aunt had died, I knew it could have been prevented. I mean, isn't there something that says healthcare is a fundamental right? But for who? So my mom is deaf and I actually have six deaf family members. I wanted to become a nurse because growing up, I saw how often deaf people's needs were ignored in healthcare. I started to focus on diabetes, which deaf people are three times more likely to develop. And I kept meeting patients like Tomiko who've been misdiagnosed or mistreated due to lack of communication and consideration. Two years ago, my doctor had told me that I was pre-diabetic. I didn't understand what that was. I was sick and really tired. I finally took myself to the ER. They told me that I had to stay overnight, but they wouldn't give me an interpreter. Every three hours a nurse would come in and give me a shot and I didn't know why. I was terrified. They were doing these tests and it was super painful. I wasn't understanding anything. I was trying to read lips. It was awful. There was no communication with me. And after two nights in the hospital, it was only after I read the discharge papers that I knew my diagnosis. Type 2 diabetes. University of Utah Medical Center. So diabetes is complicated no matter who you are and what language you speak. And here at the University of Utah, we're really striving to improve the language of care. It's about culture. It's about geography. It's about socioeconomics. Right now, health care is mostly accessible through English, which is a huge problem if you're deaf or speak another language. So Michelle and I joined forces here in Utah. What we've envisioned here is to make access to health care equal for the deaf community. And our first task was to form an all-deaf community advisory board. I was in these online deaf diabetes groups, looking for people who were open to sharing their experiences. I met Diana, Michael, and Tomiko. So this is my insulin pump. Maybe we can add a third option? And I know it's not easy, and you're frustrated with that lack of communication access. We all are. And pretty soon, we had a team from all over the country. We call them our citizen scientists, and we named the program Deaf Diabetes Can Together. Their feedback is essential. It goes directly to our team here at the university, where we have dedicated researchers, psychologists, statisticians, and design producers who all turn their ideas into reality. This is a mock storyboard, so we can see how the design of it is feeling to us. Does anyone have any suggestions? It's not just, let's get your feedback and then leave. It's, let's get your feedback and you're part of this process. Let's go Tomiko first. So the reason I signed Nearly Diabetes is because if you say Pre-Diabetes, it sounds like you don't have anything at all. They're the ones who are really driving what we do, because they're telling us what they need. They're co-designing health care with us. It feels so amazing to be a part of helping the deaf community. A part of this family, this team. We are the team. What we're learning is helping us build a new model of care for deaf patients, and one that we can replicate for underrepresented communities. I think my aunt would be so proud, together with our patients, we're changing the way health care works. The Community Advisory Board, you saw on those Zoom calls, they've been with us for the last three years, but back then when we were doing this initial design, you can see their demographics. So they were age 36 to 67. We really wanted to try and have a split perspective from people who identified as different genders, race and ethnicity, and also diabetes type, because type 1 and type 2, they have different perspectives as well. And you can see that we had about half that used some sort of diabetes technology as well. So when you think about adapting an existing program for a different type of cultural context, you have to kind of think about, well, where is the service setting and who's the interventionist? And so really, they did not want to use American Sign Language interpreters at all. They wanted to receive the information directly in sign language. So that means that the interventionists, they preferred someone who was actually deaf themselves or someone who understands deaf culture, a clinician who knows sign language. The next is, like, who are we actually providing the service for? And so the community board, they actually said, well, we want it for us, but we also want it for our care partners. So our spouses or maybe our children or someone who supports us, because we know that diabetes is managed within a social context, right? And so then now we're thinking about we have to build this not only for our deaf individuals, but their care partners who might be deaf or they might be hearing. And so now I've got to think about the hearing aspect as well. Instead of this one-day boot camp, they really wanted us to give them a full 10 to 12 sessions. And when we think about delivering a behavioral intervention, the longer the intervention, the more likely someone is to drop out. And so we get really nervous about these really long interventions, but they explain that they have been missing so much information for so long that we have to start at the basics and we have to provide this service. So they really wanted 10 to 12 sessions. We were going to deliver this virtually by telehealth across the United States. While there are hubs of deaf individuals, like in Austin, Texas or Rochester, New York, they're kind of scattered all over the country. And so we wanted to really reach them virtually. And so we decided to do virtual two-hour sessions with a break. And then some of the cultural adaptations is we all know that there are different ways to say diabetes. You can call it the sugar. You can call it different things. And there's regional accents. You might say you all or y'all. And so there are also accents in sign language. And so we needed to make sure that the diabetes terminology was all on the same page. So we had to unify those diabetes terms in American Sign Language. All of the data collection had to be in American Sign Language as well. So we know that we do lots of surveys through Qualtrics or RedCap. None of that works because it's all English-based. And so we had to figure out a way to collect in ASL. As part of deaf culture, there's these storytelling where you share your experiences. That is really important in deaf culture. So they wanted to be able to include that. And then remember those written education handouts? They wanted some sort of handout in ASL, modest incentives for participating. They felt like their children who were under 18, those are called CODAs, children of deaf adults, should be able to be involved with the program as well. And then because we were using Zoom, what happens when you get a lot of boxes is there's a lot of visual noise, meaning that if somebody fidgets around, you don't know who to look at. And so we had to spotlight signers. And then all of the ASL interpreters who are usually there signing on camera, we wanted them off-camera. And they were really voicing for the hearing individuals. And then really, what did we cover? We covered the core components of ADCES-7 behaviors. The Deaf Community Board really wanted expanded information on nutrition and medicine because they felt like that was especially lacking. And then they felt like we needed to cover ASL interpreter advocacy. So even though that's not a true diabetes topic, if you don't have that interpreter at your diabetes visit, you're not going to get the information you need. And then we added goal setting as well. So I talked about how we needed to unify those diabetes words. So this ASL glossary of diabetes terms, what we did is we created a list of 42 different words that were commonly used words in diabetes. And insulin was one of them. So if you have this shaking eye, this shaking eye can actually mean insulin, infection, or insurance. It depends on the context in which you use it. But those are all health terms, right? And so that could be really confusing. And then it was also confusing to our community board that there's insulin that's medicine and then there's also insulin that's made by the pancreas. And so they decided they wanted two separate signs. So now you've got a cell and insulin inside that cell is insulin by the pancreas or insulin and then medicine is two separate words that now becomes that insulin that becomes injected. And so we did this. So we created 42 new words in sign language with a community board. And then we also have what is called expansions where it's really explaining what that word means in sign language. And then we did a data collection in sign language. So we had to do a novella consent video. The style of when you talk to someone who is deaf and they're telling you a story about two people, they do what's called shoulder shifting. So I'm going to sign as this person and then I'm going to sign as this person. We see this a lot now on TikTok or Instagram, but this has been done in sign language for And so we did a consent video with a style of two people talking. And then we had to do Home A1C kit. We had to do a QR code that then takes them to a video. And then as you can see on the right, I don't know if any of you have taken a RedCap survey, but RedCap has a plugin where you can put in videos. And so what happens as soon as you click on the question, a video plays that tells you this question, what type of diabetes do you have? Then the subsequent responses play in that video loop. And then you can see the blue camera. So if you've missed that sign, you can go back and replay that. And then we created these diabetes education videos as handouts. So these are videos that they can now go rewatch at home as the handout. And so what we did is we had two nurse practitioners and another health educator write scripts in English. Those were then translated by a native deaf signer and then produced in a deaf production studio, which we're so lucky to have in Utah. So what we have is we have a deaf actor in the center. You can see behind the green screen. Over to the left is a language consultant who is deaf. We have the person in front of the video camera. She's an ASL interpreter plus manages the camera. Then you see me. I'm there making sure that the signs make medical sense. So sometimes, for example, if you think about mixed insulin, this is the word for mix. But when you say mixed insulin, that doesn't really make sense. What's happening is you're taking insulin from one vial and then you're taking it from another. And so that's a better concept in sign language for mixed insulin. And then we have a certified deaf interpreter who's really looking to make sure that the emotion and all of the sign is fluid. So this is an example of what our diabetes education videos look like. If you've ever seen a video that has a signer, I don't know if any of you have HBO and have seen Barbie. It's the first video that came out with a signer box. And so it's a really small box, but it's still there, which is great. We decided that we wanted to prioritize the ASL. And so we have a signer that takes up half the screen and then these beautiful visuals on the right. And these visuals are changing every sentence or sometimes every word to match exactly what's happening in the sign language. And then as you can see, we also add closed captioning. And then they have the English voiceover as well. So these are the topics of our ASL diabetes education videos. Over on the left in the first three sections on the right, those are the ADCES-7, so healthy coping, healthy eating, being active, taking medication, monitoring, problem solving, and reducing risks. And then as I mentioned before, we added two topics, advocacy on obtaining ASL interpreters and then getting that family and friend to support you. So then we did our trial, and what does our Deaf Diabetes Can Together intervention actually look like? So we started out as a 10-week, two-hour week session. It's linguistically tailored for the deaf and hard of hearing contacts, so it's delivered directly in ASL. There's lots of visuals, as you saw in the videos. It's a group format, and we really focus on not only providing that education, but skill building. So we did have a deaf epidemiologist lead, and then I was there in the background because they really wanted a deaf person to lead this. So the way I sign it is he's up here and I'm back here, and then I would pop in as needed whenever he wasn't able to answer a question, and then we did that accessible technology. So with our community board, we did a participatory trial with seven people and one care partner, and the feedback we got is they wanted it to be longer. They would really love for a deaf person who actually lives with diabetes to help teach this class, and they were hoping that there could be some sort of advanced class for those who are already tech users. As you remember, we had about half of our group that were using C-GEM or insulin pumps. So then what we did with a subsequent grant is we trained four community health workers to really help participate in this. So then in group two, we actually had the community health workers there with that deaf epidemiologist and myself, so the community health worker has a lot of support. What we also found is we were able to recruit people who were hard of hearing, or excuse me, they were deaf, but they read lips, and they weren't great at signing. And so they had to rely mostly on closed captioning, and if you've ever used Zoom closed captioning, it's not 100%. And so what we had to do is add something called CART, which is communication access in real time. So it's kind of like, if you've ever seen like a court transcriber where they're typing as things are proceeding, it's the same concept. And the feedback we got is people didn't quite understand the community health worker role, and they wanted more information about complications, and then they wanted it to be longer. And so now we're actually finishing up our next group, our third group, which we expanded to be 12 weeks, so it's actively running. So some of the positive feedback we've gotten so far is they love that it's deaf led, and that they have an ASL fluent nurse practitioner that can support. They love the live captions, they feel like it's fully accessible. The visuals in the videos actually enhance understanding. They felt like it's motivating, there's goal setting weekly, and so that's really pushing them to do more. And I think one of the biggest things is they don't feel alone. So a lot of times if you don't do a group with people who speak the same language, people feel isolated and they don't know who to talk to. And then one thing that I'd really like to highlight is every single person said that they learned more in this program than a hearing diabetes self-management education and support program, even though they had an interpreter for that. And so there's something about really delivering it directly in sign language and having that deaf context, that's really important. So one of the things that we did provide is we provided what's called language access. We provided the information directly in their language. We were available, there was linguistic and cultural competency with the provider. The interpreters were there, we had live captioning, and then we added these deaf community health workers. Also, when you think about the neighborhood and built environment, transportation was not required because it was virtual. And so that geography component was there. People talked about the sense of belonging and the absence of discrimination. There was no ableism in the program. And then economic stability throughout the program, we did provide resources for food security based on where people lived, also resources for med coupons and patient assistance programs. The one thing you might be thinking about is internet and whether or not people had a laptop or a phone to be able to access, because it's all telehealth based, right? So there's a couple of things that does happen. So we had some people who had Medicaid issued cell phones that were able to use this, and they would go to a library or they would go to Starbucks to access the Zoom. You worry a little bit less about HIPAA when someone doesn't know the language, but it's up to them to choose where they are. Also, we're working with deaf centers, which are located in different states and also libraries to support this more for those people who don't have internet or some sort of device to access the information. So our research conclusion is deaf diabetes can together improve several social determinants of health. We're designed to reach deaf and hard of hearing populations across the United States. One thing that's really important though, is we do have telehealth policy implications about crossing state lines, right? So right now this is for research, which is great, but once we want insurance to start covering, I'm licensed in the state of Utah, can I really take care of someone in Wyoming or Idaho? And then we did have some modifications that were recommended and that we've been incorporating into our current work. We do have a couple of ongoing projects, as I mentioned, we're finishing up that third group. I do have a ADA grant, which is a comparative effectiveness trial with 80 people. Essentially people are getting just those 20 diabetes education videos in ASL, or they're getting the full 12 week program with a community health worker, and that'll be active through next year. And then we did receive what's called a G08 from the National Library of Medicine. For those of you who are researchers in the room, a G08 is really focused on providing a technology to an underserved community. And so we're providing the first diabetes education website in American Sign Language. I wanna mention that there's this concept called deaf gain. So deaf gain means that something was built for deaf people and now everybody gets to participate and use it. So TTY, which was the first telephone for deaf people, as you can see, it's a type based system that was built out in 1964. And that was the first text message. And now we have text messaging, right? The other thing is the first picture phone was built for deaf individuals also back in 1964. And now we have FaceTime, we have Zoom, we have all sorts of teleconferencing things. So there's a lot of things that can be built for one disability group or other cultural group that actually a lot of people get to gain from. And I will say that the Deaf Diabetes Can Together, the videos, the different visuals that we're using, I actually use those to teach our nurse practitioner students pharmacology. And also I have a student who will actually be here for the reception who is finishing up her DNP and PhD. And she's actually adapting the program for Native Hawaiian Pacific Islanders. And she had the choice, she could take our program from the original hearing English program, or she could take content from the deaf program. And she said, we definitely need the visuals from the deaf program to support the Pacific Islander community. So there's a lot of deaf gain when you can actually expand it to the broader communities, right? So I was asked to provide a few tips. So for the researchers in the room, don't assume you know what a population needs, find those community collaborators. And so there are different people who are in positions of power within communities that are great. So like a leader of, in my world, it would be like a leader of the deaf center or a lead of a ASL interpreter agency. But also you've got to talk to people who actually live with the condition you want to study that are in that cultural context. And then I think it's important that you make research accessible. So a lot of times what we do now is we, if we're going to do research, we actually exclude based on certain languages. And now, I don't know where, at the institutions where you're at, but at the University of Utah, they've made it that you have to actually give a reason why you're excluding based on language, because our institution provides interpreters for all research activities. So really think about how you can make your work more accessible. And then for the clinicians in the room, ensuring that interpreters are present if requested. We have done some research that has found that there's actually a power imbalance. If a deaf person requests an interpreter and isn't provided one, and then that clinician comes back and says, hey, we need an interpreter, one is actually provided. It shouldn't be that way. It should be that patients just get to have that interpreter, but we see that happen again and again and again. So be that advocate for your patient. Make sure that interpreter's there. Also, family and friends should be care partners and not interpreters. And what that means is when you ask a spouse or a child to interpret, you've actually given them information before the patient, and they may not actually interpret everything correctly, right? I remember being about 10 years old where I actually had to tell one of my aunts who wanted a cochlear implant that she will never hear again. And I made her cry as a 10 year old. And I remember that feeling, feeling just awful. And it creates a situation you don't want that person to be in. You want that person to just be that support person. I also mentioned care for people as if they're your own family or your own mom, because you might be taking care of my mom one day. So please do a great job with people. Also refer for diabetes self-management education and support. We know that a lot of times these are done in group settings, but really one-on-one is better for a deaf individual. And then if there is someone else in your practice or someone in your town who speaks that same language, it's actually better to refer so there's language congruency. So if I knew that there was someone else that used sign language, I would prefer that person for my mom. And I know she would prefer that too. I do wanna do a quick plug for some of the ADA sessions that we're giving. So my colleague and I, Allie Hughes in the back, we're doing a state of health equity and disability supporting diabetes technology usage for people who are deaf and hard of hearing or blind, low vision. And then also we're doing a live ASL interpreter workshop for clinicians. So if you wanna know what it's actually like to work with an interpreter, we're doing a live hands-on workshop on Sunday. So those are both happening on Sunday. We do have, people can refer to our Deaf Diabetes Can Together program. This is the website and our phone number. VP stands for video phone. So a patient can actually call and then do sign language with an individual. And I'm gonna teach you a sign. So put your hand out like this and then take your fist and go wrist first and then over to the elbow. You've just made the sign for structure. So if we have quality healthcare and we provide language access, which means language in someone's primary language, then we're all gonna improve deaf health outcomes. So this is just a slide on the funding that I've received over time. And this is our team. I like to say that those in purple borders are people who are deaf on our team. And we include our community advisor board in that. If there's an orange border, that means they're a CODA like me. So a child of a deaf adult. And then the black borders are people who are hearing. And then we've got stars for our trainees. I will say that the person right here is a, he's gonna be the next deaf dentist in Utah. He just got into dental school and will start in the fall. And this is my student who's working on the Pacific Islander program. So with that, I say thank you and happy to entertain any questions. Dr. Lishman, this was one of the most inspiring talks I've heard. I think this work out captured as your calling and it's benefiting so many people. So I appreciate it. I open for questions and then I'll have some for my own. So you mentioned your institution will, I may have gotten this wrong, but they'll send an in-person interpreter for any research participant. Is that right? What happens with the University of Utah is we have a special system in which we request interpreters for study participants. And it's funded through our vice president of research office. And that's pretty new. So it's happened with maybe less than a year ago. Do you know how that happened? That's amazing. Like what sort of advocacy or policy, like pushing for that policy had to happen for it to happen? Yeah, so that's a great question. So I do this with diabetes research, yes, but I also do advocacy for the deaf employees at the University of Utah. So we have six across the university system. We have a couple in the health scientist space and then we have a couple on main campus as well. And what they have all told me is that they actually don't request interpreters because their departments are small and they were told that there's not a lot of funding. And so they're sort of being told that there's not a lot of funding for them. And so what happened is we actually went to HR, requested a pilot for our employees to get interpreters and also for study participants. The reason why is for study participants specifically is if you use grant funding for interpreters, you actually decrease what you can do for participants. So it's already unequal. So if I need to put in a certain amount for interpreters, maybe I have to reduce my sample size by 40 because of that. And now we have a different type of research, right? Because we don't have the same power. And so you can use that argument. You can also say that another institution is doing it if you want to maybe do that plug because definitely the U has started doing that. And I'm sure that there's probably a couple of others as well. That's great, thank you. Yeah, thanks for the question. Hi, I wanted to ask where do you see your work in 10 years from now? Yes, I love this question. So I've always been a diabetes researcher and a nurse practitioner, but you sort of said this calling. I do feel like I'm one of the few people who can bridge to other disease states as well. So our next goal is to actually really focus on cardiovascular health, add that blood pressure, cholesterol, stroke, all of those components. And then I sort of see this umbrella of deaf health can together. So now you've got an arm for diabetes, cardiovascular, kidney, asthma, cancer, all of these other disease states so that deaf individuals have a really nice, solid place for diabetes health education, I'll say. The other thing that I'm really interested in is really providing this network of our, we have many colleagues who are deaf doctors, deaf nurses, and sometimes they have challenges getting jobs, but this is the perfect job for them where they can communicate directly. And really that challenge is that telehealth policy across state lines. And so that's the next thing that I've been trying to work with. Thank you so much. Any other questions? Hi, I have a question. I hope I'm loud enough, but, so what's a good resource for people to get into ASL and especially in the medicine context? As somebody who has not delved into it before, I would really like to explore more. So if you have any resource recommendations, that would be really great. Yeah, so the question was, how does a clinician get more information about deaf populations or learning ASL? So in the state of Utah, ASL classes are actually free through classes level one through two. So you could check with your state. You could just Google ASL classes and then put your state. We do accept out-of-state individuals. They usually get put on a waiting list because they prioritize Utahns, but we have had other people and it's all Zoom-based. And so it's free. I will say that the best sign language classes are taught by deaf individuals. And you might think like, well, how am I gonna be able to communicate? You actually learn faster and you learn how to, I mean, these deaf instructors have been doing it for a long time and so they know how to communicate with you. You've just got to get used to being uncomfortable and trying to figure out that piece back. But yeah, there's a lot of free classes that are offered by the Division of Hard of Hearing Services in different states. Yeah, great question. Videos that you have available for other folks or is it still just in the research phase right now? Yeah, I love this question. So one of the things that we've done at our institution is we've asked, can we actually have all of these videos uploaded in Epic so that they can be provided as patient education? So when you click on something, it goes right into the portal. What will happen with our work, and we just got this approved a couple of weeks ago at our institution is you'll, instead of having a video pull into your portal, you'll have a document with a QR code pull over. And then that QR code will take you to the video. We know that sometimes based on other things that have happened at the University of Utah that we've uploaded into Epic, that those then go reach other institutions. And then I mentioned the website that we're building out. So that will be finished in 2025, and that will house all of the diabetes education videos. Since we've done, in addition to the 20 that we've just done, we had sort of a retreat for deaf clinicians and our community board back just a month ago and recorded a video on diabetes, diabetic ketoacidosis, oral health and diabetes done by a deaf dentist, and then also vaccines that are important if you have diabetes. So we're still trying to build our library, and those will all go on a website at some point soon. Yeah, great question. I have a question about diabetes technology, and both for the deaf community, but also I personally have had experience with blind individuals just really not being able to access the technology because for the deaf population, maybe they can hear the low alarms on the pumps, and both blind individuals not being able to use even pens safely all the time. Do you know of any, I don't know, other options or other companies that have accessibility, like ways to make that more accessible that I just may not know about from an academic setting? Like is there any, besides just talking to a commoner or a local partner, is there anything else? Yeah, so that's a great question, and that's actually the topic that we're gonna be, Allie and I are gonna talk about on Sunday. So you might look for that presentation. With just the two minutes I have left, I'll just give a brief response, and then I'm happy to chat with you after. But a lot of the accessibility actually comes through smartphone devices. So a lot of these droids and iPhones, which actually have better accessibility than the device themselves. So for example, a CGM system that has an app within a smartphone, it can actually create what's called a flashing alert alarm. So your flashlight becomes a flasher. And so deaf people appreciate flashing lights. Also your phone can vibrate. There are challenges though. So with a vibration setting, you can't change the strength of a vibration setting. So like if you have an Eversense, Eversense is the only device that actually vibrates on the skin, but you can't change the strength of it. So there's still challenges, but I will say the main aspect is the accessibility through existing smartphones. And then I'm happy to discuss further with you too. I think we are out of time. Yeah, we're out of time. Thank you so much. A round of applause. Thank you so much. And we'll see you all outside. Okay, I'm coming up for like a couple of minutes. Okay, so we are almost done. I promise I won't hold you up too long. And then we can go get our networking on, which is we'll learn more about tomorrow, but we can practice today first. Okay, so before we dismiss to the networking event, the ADA would like to recognize the 2024 recipient of the Andrew P. Goldberg Early Career Award. Very exciting. So the ADA has established this award in recognition of Dr. Goldberg's exceptional contributions to the field of aging research and diabetes and his lifelong devotion to mentoring. Throughout his career, Dr. Goldberg's research was focused on the role of lifestyle, physical activity, and obesity on the metabolic precursors for type two diabetes and its complications, including cardiovascular disease in older adults. He was a dedicated mentor who was passionate about supporting the growth and development of young clinical researchers in the field. This award is intended to serve as a meaningful tribute to Dr. Goldberg and his means of sustaining his legacy by supporting the growth and learning of others pursuing a career in clinical or translational research. This prestigious award is supported in part by the Goldberg family who are with us here today. Thank you so much. I'm happy to announce that this year's Andrew P. Goldberg Early Career Award goes to Sok Chin Thai. If she could come up, that would be great. Okay, all right, congratulations. Okay, and with that, I think we are good to go ahead and wrap it up. So the networking event will be right outside the doors. And then tomorrow morning, we are a little bit earlier, sadly, but we can do it. So breakfast starts at 730. And then the program starts at eight tomorrow morning. And thanks everyone and enjoy your evening.

ADA Scholars Program

endocrinology

diabetes research

Dr. Brittany Bruggemann

Dr. Earl Hirsch

diabetes technology

insulin pumps

continuous glucose monitors

career pathways

mentorship

research funding

Dr. Elizabeth Seaquest

employment contracts

social determinants of health

Andrew P. Goldberg Early Career Award