As reflected in Profiles and Perspectives, many who choose a career in academic gastroenterology and hepatology eventually wear the hats of researcher, clinician, administrator, and educator. As I look back upon my career, I think that my most fulfilling role was as a medical educator. Although writing original research articles, syntheses of state-of-the-art research, editorials, book reviews, chapters in digestive disease textbooks, and a handful of books were important, lecturing has given me the greatest pleasure. My introduction to speaking before a large audience occurred when I taught second-year medical students in what was then called the Biology of Disease Course, initially at Harvard Medical School and then at Boston University School of Medicine. As a gastrointestinal (GI) fellow at the Massachusetts General Hospital, I spoke occasionally at GI Rounds, and, later, as a teaching attending at the Veterans Administration (VA) Hospital in Jamaica Plain and at Boston City Hospital, I gave a number of what might be called mini-lectures. Across my career, my teaching efforts have been directed largely toward house officers in medicine, trainees in gastroenterology and hepatology, and both academic faculty and community practitioners across the USA and abroad. In what follows, I will recount some of the more memorable events of my educational efforts.

My Maiden Voyage

My first experience speaking before a medical audience occurred while I was a fourth-year medical student serving an elective subinternship in Internal Medicine at Goldwater Memorial Hospital on Roosevelt Island, under the supervision of Dr. David Seegal. I distinctly recall that event now, 55 years later. Shortly after I had begun to speak, Dr. Seegal interrupted me to suggest that I keep my head up so that I could be heard more easily, because, he predicted, I would eventually be speaking before audiences in the thousands. How prescient he was and how grateful I remain for his interest in me, which continued for many years thereafter. Perhaps what is most interesting to me about this recollection is how determinative that observation of Dr. Seegal’s was; without it, perhaps, the course of my career might have been somewhat different.

Learning to Speak Comfortably

Shortly after arriving in Boston to work with Tom Chalmers as an Epidemic Intelligence Officer of the Public Health Service assigned to the Boston Inter-Hospital Liver Group to study viral hepatitis, I was asked by the Postgraduate Medical Institute to give a lecture at a 25-bed hospital in Great Barrington, Massachusetts. I wrote out my entire presentation on the relationship between hepatitis B and cirrhosis and rehearsed it in front of a mirror for several days. I approached the day of the talk with apprehension, but the warm and appreciative reception I received from the six or seven physicians in attendance gave me the confidence I needed. I found myself actually enjoying the experience. Being invited back for additional presentations provided validation that this was something I could become good at, and I really began to look forward to more speaking opportunities, which came frequently. For a number of years, I served as a member of the faculty in a Boston University medical education conference held annually on Hilton Head Island. When the staff of the local 93-bed hospital invited me to join them for lunch and case discussions, I began to understand more clearly the educational needs of clinicians, as well as how my potential role as an educator could be beneficial.

Visual Aids

There is an art to making and using visual aids to present complex information. Designing strategies for the most effective displays of information requires knowledge of principles of learning and cognition. For example, there is a limit to the number of bar graphs that can be comprehended on a single slide. Familiarity with the extraordinary work of Edward Tufte, the father of modern information design, is helpful. I was fortunate to have served on the Clinical Teaching Project (CTP) of the American Gastroenterological Association (AGA), which was tasked with developing slide sets for use in GI training programs. Participating in small groups to design and later present draft slides to the collective wisdom of the group was exceedingly helpful. I often used the set we developed on viral hepatitis when giving continuing medical education (CME) lectures. Based in part on my experience with the CTP, I was subsequently asked to develop slide sets for a number of pharmaceutical companies, including Merck, Glaxo, Roche, Schering, and Amgen. Each of them also invited me to join their Speakers Bureaus. In addition to crisscrossing the USA on speaking tours, my travels as a lecturer have taken me to South America, Asia, Europe, and Africa.

Speaking Slidelessly

On a number of occasions, I have given lectures without the use of visual aids. The first time this happened was not intentional, but the bulb on the 35-mm slide projector had burned out and a replacement bulb was not available. I asked that the room lights be turned back on, and I probably spoke for about 35 min and then used the rest of the time to answer questions. Surprisingly, rather than becoming discombobulated, I found myself rather enjoying the experience. Another time, I had carried my 35-mm slides, secured by a rubber band, in my jacket pocket onto a small plane flying from Boston to upstate New York. I had not brought a carousel. After arriving at the hospital where I was to speak, I realized that my slides must have fallen out of my pocket during the plane ride. Having already given a slideless presentation, this time was easier, and again, I found that I was enjoying the experience. Arriving back at the airport, I was approached by the pilot, who had found my slides. Lesson learned, I carried two sets of slides with me for a number of years, or brought a loaded and locked carousel.

My first purposeful slideless lecture occurred at a combined University Hospital/Boston City Hospital Medical Grand Rounds. After being introduced, I proposed that rather than giving a “canned” lecture, I would be happy to respond to questions about my subject, which almost inevitably was some aspect of viral hepatitis. For the next 55 min, there was no break in the questions, and I received a standing ovation. A few years later, I was invited to give Grand Rounds at Norwalk Hospital in Connecticut. I had heard that Martin Flock, the Chief of Medicine, was adamant that speakers always use slides. I had prepared a carousel with my slides, but after I was introduced, in an effort to be funny, I pulled about 15 non-medical slides from my pocket and tossed them randomly at the audience, saying I did not think I needed these. When I saw the horrified look on Marty’s face, I asked for the first slide on the carousel. I was never invited back.

Adding Humor to a Presentation

Some years ago, while walking on a beach in Wellfleet, Massachusetts, where I vacation in the summer, I happened upon a large rock shaped like a human liver, complete with an anatomically appropriate fissure. I painted the rock a liver-like color. When I was invited to give Medical Grand Rounds at Yale-New Haven Hospital, I brought my liver rock in a paper bag. After I was introduced as a Professor of Medicine from Boston University, I noted that I had recently learned that for financial reasons Princeton had donated its paleoanthropology collection to Yale. I stated that as the curator of the poorly endowed Boston University’s School of Medicine collection of fossils, I also wished to contribute our collection to Yale. I pulled the rock from its bag, saying that I was pleased that this fossilized human liver would now join Yale’s famous collection, and handed the rock to Sam Thier, the Chief of Medicine, who I knew from my days at the MGH, to thunderous, cheering applause and laughter. Later, Sam gave the rock to the late Caroline Riely, a Yale hepatologist with whom I had worked, who took it to Memphis with her when she joined the faculty of the University of Tennessee. On my visits to Memphis over the years, the rock was moved from Caroline’s office bookcase, and when last seen by me, it had become a doorstop in the GI Division.

Learning Humility

Many years ago, I was asked to speak before the Oklahoma Medical Society. The subject was hepatitis B. When I arrived at the airport in Oklahoma City, I was picked up by a pharmaceutical representative and driven to a one-story building in which were set about 25 tables with about 6 chairs around each. My physician hosts suggested that I try the barbecue buffet and directed me to take my plate to the stage on which sat a lone empty table with two chairs. My initial concern was that the purpose of this was to see how someone from Boston handled barbecue. A few minutes later, one of the physicians joined me at the table, and I relaxed. He indicated that a benediction would precede my talk. He rose and in a loud voice but with bowed head proclaimed: “Lord, protect us from DRGs, HMOs, and PPOs.” I almost laughed out loud at the notion that these changes could be stopped by divine intervention. A second physician then climbed onto the stage and jokingly said to the audience, “I have good and bad news. First the good: the Oklahoma City physicians have defeated the Oklahoma City lawyers in basketball. The bad news is that we have a speaker tonight.” I gave my talk, which I thought was well received, despite the introduction. About 2 years later, my wife and I were window shopping in Bal Harbor, Florida, when we were approached by a smiling young man. He said that he had heard me speak to the Oklahoma City Medical Society a few years ago. I quickly responded: “How was I? “Oh,” he said, “you were good, but a month later we had the University of Oklahoma cheerleaders, and they were sensational.”

Speaking of memorable introductions, several years ago I was invited to give a presentation to the West Indian Medical Society in Trinidad. The physician who introduced me said he had read most of my publications and found them to be good but not outstanding. The audience appeared stunned. When I walked to the podium, I thanked the man for his remarks but added that, if my mother had been here, she would have smacked him and insisted that my publications were, in fact, magnificent. The laughter that followed relaxed the audience and me, and after my lecture, profuse apologies were offered.

Gimmicks to Break the Ice

As the moderator introducing a symposium on hepatitis C virus, which had only recently been identified and partially characterized, I tossed into the audience in the first row a plastic, spiky orange 3-inch roller ball used for massage, and asked that it be passed around. I instructed people to look at it carefully, since it was the first known model of the hepatitis C virus, and said that I must have it back by the end of the symposium. No one was fooled, but nearly all enjoyed the ruse. Of course, subsequent studies suggested that the virion did have projections on its surface.

Pseudo-dangerous Moments

Another time, I was asked to give Medical Grand Rounds at the University of Vermont. About halfway through my presentation, I decided to use the blackboard, which was covered by a projection screen. When I raised the screen, I found a chalk drawing of a penis and testes, with the name of a woman and the statement that she performed fellatio, albeit in more colorful terms. I quickly lowered the screen and stated: “I did not know that happened in Vermont,” which produced an uproar and, I have been told, created a lasting memory for those present that morning. (The woman apparently was a custodial supervisor.) I certainly did not forget this episode, and when I returned to Burlington a few years later, I lifted the screen before speaking to be certain that the blackboard was holding no surprises.

On a more serious note, during a talk at a Massachusetts hospital, I was interrupted at the very beginning of my presentation by a man in the audience who stood up and asked a question. I thanked him for the question, which I said I would answer in a few moments since I had planned to cover the area in which he was interested. However, he did not accept this response and wanted an immediate answer, which I decided to give. He sat down, and I continued with my lecture. However, every 10–15 min he would rise from his seat and step a little closer to where I was standing. This was a bit unnerving. After about a half hour, he came within a few feet of the podium but then disappeared behind me, not to return. Later, his colleagues in the audience explained that he meant no harm and that they should have warned me about his behavior before I spoke.

The Show Must Go On

Some of my experiences have presented physical challenges that needed to be overcome. Some years ago, I had been invited to give two lectures on liver subjects at a board review course in Internal Medicine at a New York hospital. A few months earlier, I had developed tinnitus and a mild hearing loss in my left ear, followed by episodes of disabling vertigo, associated with sweating, nausea, and vomiting. The bouts of vertigo occurred without warning. A diagnosis of Meniere’s disease was made, but none of the usual treatments were helping. Undaunted, I had continued to travel and lecture. My first lecture proceeded without incident. Another speaker followed, but at the end of his lecture I experienced vertigo, which did not abate when I arose to present my second lecture. I resolved to speak but instead of facing the audience, I turned to face the screen and gave my talk with my back to the audience, sitting in a chair, which seemed to reduce the vertigo. I explained this to the audience. About 10 min after I had finished, I felt well enough to get a taxi to LaGuardia Airport and fly home. Fortunately, with the exception of the hearing loss, my other symptoms eventually abated and resolved completely.

How to Be Disinvited to a Lecture

In 2014, I was invited to be the keynote speaker at an Immunization Summit in West Virginia. West Virginia had the dubious distinction of having the highest incidence of acute hepatitis B in the USA for several years, largely due to a rising rate of injection drug use. I was pleased to accept the invitation because I had spoken many times in West Virginia to public health personnel and knew of their concerns. I assiduously reviewed the available information from the West Virginia Department of Health and the Hepatitis Branch of the Centers for Disease Control and Prevention (CDC) to be certain that my information on hepatitis B in the state was up-to-date and as accurate as possible. Neither the Department of Health nor the CDC were as cooperative as I had expected. I contacted the medical schools of West Virginia but found that interest in hepatitis B virus prevention was limited. I also attempted to reach both US senators and the Governor of West Virginia to better understand the federal and state programs on preventing hepatitis B. I did reach Senator Manchin’s office in Washington but was told that hepatitis in West Virginia was not a high priority. I included some of this information in the slides I had prepared for my presentation. A few weeks before my scheduled talk, my hosts asked for my slides, a somewhat unusual request in my experience, and I complied. I subsequently received a phone call indicating that I was disinvited to the Immunization Summit. Apparently I had been asking too many questions and making too many suggestions about how to deal with the epidemic. I have no regrets, since I learned a lot researching the topic, and even more about politics. West Virginia still has the highest incidence of hepatitis B in the USA, and neither the federal nor state government has made this a priority, although in 2016, the CDC finally reported the increase in the incidence of acute hepatitis B in West Virginia, Kentucky, and Tennessee, which had been known for several years but largely ignored.

Other Venues for Lecturing

Some years ago, Bill Steinberg organized a medical education course, which I think was called “Sail and Learn.” The GI faculty lectured with slides in a classroom on the beach in St. John, and after about 2 days of lectures, faculty and students took off in small sailboats to explore that part of the Caribbean. They returned 2–3 days later for another series of lectures and then departed for home. The experience was delightful, since the audience was composed largely of experienced gastroenterologists and the faculty were both accomplished speakers and experts in their fields. Also, the sailing was great.

Conclusion

In retrospect, much of my career has been focused on communicating with house staff, trainees in the digestive diseases, and mid-level, academic, and community practitioners. Speaking has been an exciting, enjoyable, sometimes amusing, and always gratifying experience. When I started out, the multiple directions my journey in medicine would take me never entered my mind. I cannot think of a more fulfilling career path.