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A Conversation with Mitchell Shiffman, MD

In 1989, Mitchell Shiffman, MD, was coming out of his fellowship at the Medical College of Virginia at the Virginia Commonwealth University in Richmond, Va., and looking for his next step. He knew he wanted to maintain his location, but the only position open was in the newer field of hepatology. So, he took it.

Less than 1 year later, his hepatology Section chief, Robert Carithers, MD, left the Medical Center to start a liver transplant program in Seattle, Wash. Shiffman, who was the only other member of the hepatology group at that time, became the de-facto section chief of hepatology and the Medical Director of the Liver Transplant Program, positions he held for the next 20 years. Over the few years Shiffman added four additional faculty members to the hepatology section at Virgina Commonwealth University Medical Center, developed a clinical trials program, expanded the liver transplant program and vaulted the VCUMC into one of the best and well recognized hepatology programs in the country.

In 2009, Shiffman left VCUMC and started the Liver Institute of Virginia at the Bon Secours Health System. His goal was to bring liver disease and its evolving treatments to patients in the community so these patients and their families would no longer have to travel long distances to large medical centers for care. In just 5 years, the Bon Secours Virginia Liver Institute has become one the largest clinical practices devoted to caring for patients with liver disease in Virginia. He maintains a strong presence in clinical trials while best serving the needs of his patients from curing their hepatitis C virus to matching them with the best option for a liver transplant.

He is working with the American Association for the Study of Liver Disease to bring his expertise in community care to other practicing hepatologists.

What was the defining moment that led you to your field?

I wasn’t even thinking about doing liver disease, but when I finished my fellowship and I wanted to stay on the faculty, the only position we had was in the liver section, which was just starting to grow. I was the second hepatologist hired.

I was there 6 months when my section leader and mentor left. That’s how I became section chief of hepatology for 20 years.

You need to explore your opportunities. I had the opportunity to get into liver disease and it’s turned out pretty well.

We had no treatments for anything when I started. The last thing my section chief and mentor told me was, ‘I got this email about something called interferon for non-A, non-B hepatitis. I’m going to forward it to you and you should follow up on it.’

What area of research in hepatology most interests you right now, and why?

I’m now in a practice environment in a large health system and I predominantly take care of patients. We’re always looking to how we’re going to better the care of patients.

We’re looking for better drugs in hepatitis C. We want more drugs to come out. Stefan Zeuzem, MD, said after his talk this morning: ‘We need competition. I like competition.’ That’s the same way I feel. With the restrictions for treatment that are in place now in the U.S. and other countries, the only way those restrictions will be lifted if we have more drugs on the market, more competition, lowering of prices. Then we’ll finally be able to treat everybody with hepatitis C.

What advice would you offer a student in medical school today?

You have to keep your options open. Look at all your opportunities; don’t cast off any opportunities indiscriminately without exploring them. You never know what you’re going to leave behind and regret.

Medicine is still a good field and you’re going to help a lot of people. However, medicine is changing tremendously. Our new physicians are being taught to care for patients through software programs and algorithms. While technology can certainly be used to assist in patient care, I am concerned that there is too much reliance on technology. Not all patients and not all disease processes fit the algorithm. It is therefore still very important that today’s students and trainees understand physiology and pathophysiology of disease. Without this foundation, our new physicians will not be able to solve the complex medical problems that do not fit the algorithm.

The other thing in medicine that is changing is the time commitment. Throughout school and medical training the number of hours of patient care is limited. Physicians now work their “shift” and then go home. Unfortunately, patients do not always need your help during your “shift”. So I am concerned that the next generation of physicians will see medicine as their 9-to-5 job instead of as their profession.

Have you ever been fortunate enough to witness or to have been part of medical history in the making?

We’ve lived medical history. We’ve gone from taking a disease that had no name to identifying a virus to having a bad treatment to having a less bad treatment to having a treatment where we can cure virtually everybody in a relatively short amount of time.

I have been very lucky that my career started at the beginning of the hepatitis C story and I am hopeful that in the next decade, before my career ends, that the hepatitis C story will come to an end and everyone in the U.S. will be cured of hepatitis C.

What’s up next for you?

We’ve built a very nice practice in a large health system which covers a large part of Virginia. Our goal is to continue to expand the Liver Institute and to continue to take the care of patients with liver disease into the community so these patients do not have to travel great distances to large centers for care. My goal as the first Chair of the new Clinical Practice Special Interest Group within AASLD is to show other gastroenterologist/hepatologists how to develop similar programs.

Hepatology has evolved as a field so that it doesn’t have to stay in the silo of academic medical centers any longer. We can take care of patients with all liver diseases, cirrhosis, liver cancer and provide both pre- and post-liver transplant care in a community setting where it is more convenient and efficient for the patient and their family. Although we do not perform liver transplantation in our Health System, we discuss the transplant process with each and every potential patient and identify the best liver transplant program for them based upon geography, family support, disease state, patient preferences and other issues. Our patients then undergo all liver transplant evaluation testing and pre-transplant management locally near their home at the Liver Institute and visit the liver transplant program of their choice once the evaluation is complete and we know they are an acceptable transplant candidate.

We then manage all pre-transplant issues while the patient is waiting for their liver transplant. After the transplant, the patient comes back to us and receives all post-transplant care locally at Liver Institute. We have dedicated RN navigators who assist our medical providers and communicate with the various liver transplant programs we work with on a regular basis. This is a new model by which liver transplant programs can grow. Instead of outreach programs, where the hepatologists from a transplant center travel to far away communities and identify patients for their program, this approach develops partnerships between community-based hepatolgists and transplant centers, which is more patient-centered, cost-effective and rewarding for the community-based practicing physician.