Introducing the AASLD president: Guadalupe Garcia-Tsao
Authors: Roberto J. Groszmann
Journal: Hepatology (2012)

NIH, National Institutes of Health; VA, Veterans Administration. Guadalupe Garcia-Tsao, or "Lupe" or "Lupita" to family and to the large group of friends and colleagues that she has all over the world, was born in Mexico City. Her mother was Chinese and her father Mexican. In Mexico City, Lupe initially attended a private school; however, she was happier in the public system where she completed high school, as well as medical school. She studied medicine in the largest and most renowned Medical School in Mexico, the Universidad Nacional Autonóma de México. At the time of Lupe's studies, over 80% of the medical students were male. It was this competitive environment in which Lupe excelled. While in Medical School, she read a small booklet by Horacio Jinich called "The Jaundiced Patient" which very simply and graphically explained bilirubin metabolism. She felt she could make the diagnosis in any patient with jaundice. On her clinical rotation, her fellow students knew to call Lupe whenever a jaundiced patient would show up. It was then that she began to interact with the liver attendings, among them a young David Kershenobich, who just returned from a fellowship with Professor Sheila Sherlock. She became more and more interested in the liver and during her last year in medical school she involved herself in liver collagen research with Dr. Kershenobich and Dr. Marcos Rojkind. By then they had started a placebo-controlled randomized controlled trial of colchicine in the treatment of cirrhosis. Lupe was involved in this trial at an early stage (randomizing patients, supplying medications and collecting data)and she got hooked on clinical research. The study was published in the New England Journal of Medicine. Before graduating from medical school, Lupe knew she wanted to pursue a career in hepatology. She competed for a residency slot at the Instituto Nacional de la Nutricion, the premier and most coveted postgraduate medical institution in Mexico with an acceptance rate in the single digits. She was accepted and spent 3 grueling years in this institution; at the time, there were 4-month rotations during which she worked 120-hour weeks. She decided to stay on and do her gastroenterology fellowship at the same institution so that she could continue her liver research work. During her fellowship she spent one year in the laboratory of Rojkind after he had returned to Mexico from Einstein. Even though Marcos was enthusiastic about her future potential as a basic researcher, Lupe realized that her place was with patients and in investigating clinical questions. Thus, she declined his offer to work on a doctoral degree. Back in the clinical setting she worked at answering questions about, among other things, the effect of acute alcohol intoxication on blood markers of collagen synthesis. This study was more stressful than she had anticipated (try drawing blood from a bunch of intoxicated people!) but resulted in a paper in Gastroenterology. As her fellowship was ending, Lupe knew she wanted to pursue clinical research in liver diseases and knew that she wanted to go abroad, as her mentor had, to learn more about research methodology. She sought different possibilities and finally she decided to accept a fellowship position at the West Haven Veterans Administration (VA)-Yale University with Dr. Harold Conn. At the time there was an incredible amount of "liver talent" concentrated in New Haven: Jim Boyer, Caroline Riely and Adrian Reuben at Yale and Harold Conn, Roberto Groszmann and Colin Atterbury at the VA. The services were integrated under Jim Boyer and the fellows rotated through both hospitals. On her first visit to West Haven, she met and had dinner with an outgoing research fellow from Barcelona, Jaime Bosch. Little did she know that years later he would become a close collaborator and friend. Shortly after Lupe's arrival, Harold Conn left for a one-year sabbatical in California and Roberto Groszmann became acting chief of the Liver Unit at the VA. This serendipitous juncture allowed Lupe to become involved in clinical research studies with Roberto Groszmann, thus initiating an extraordinary and productive partnership which has been ongoing for almost 30 years and which has resulted in 30 publications in peer-review journals that have changed the knowledge and practice of portal hypertension. Once Harold Conn came back from sabbatical, Lupe embarked on studies of spontaneous bacterial peritonitis, a term that was coined by Harold, and this led to her continued interests in other complications of cirrhosis, such as ascites, SBP and hepatorenal syndrome. After completing 3 years of hepatology fellowship, Lupe returned to Mexico to her alma mater, the Instituto Nacional de la Nutricion, because she considered it her duty to share with the young medical students, residents and fellows all that she had learned in the United States. Given the economic constraints in the academic environment at the time, Lupe set up a separate private practice. She nevertheless remained productive and continued to mentor, among others, Paul Angulo of NASH fame when he was a medical student in Mexico. In 1990 Lupe was recruited back to Yale as an Assistant Professor of Medicine. She agreed to come but rather than relinquish her position in Mexico, she took a "leave of absence" because, she said, the thought of leaving Mexico forever was very difficult. This was 22 years ago and she is still at Yale. During this time she rose through the ranks and became Professor of Medicine in 2002. She continued to perform clinical research studies in the areas of portal hypertension in collaboration with Roberto Groszmann, Norman Grace, Jaime Bosch and Andrew Burroughs, and many others mostly in the performance of randomized clinical trials and proof-of-concept trials with portal pressure–reducing drugs. She has also pursued research in the area of other complications of cirrhosis and, most recently, in further defining the natural history of cirrhosis. She received a K-24 award from the National Institutes of Health (NIH) in 1999 to support her research on complications of cirrhosis. For this research, Lupe has received funding from the VA and the NIH. As the current Chief of Digestive Diseases at the Connecticut-VA Healthcare System, she is following in the footsteps of her mentors Harold Conn and Roberto Groszmann. She is also Director of the Clinical Core of the NIDDK-funded Yale Liver Center. In 2001, she applied for and received a grant from the VA Central office to establish one of four Hepatitis C Resource Centers across the country. This grant has been ongoing for over 10 years and has been focused on improving the care of veterans with hepatitis C and their complications. This has shifted her attention to developing different tools and products that have empowered both patients, primary and mid-level providers in the management of hepatitis C, cirrhosis and its complications by providing educational tools. This has been a very exciting direction in her career and she has been involved in the development of educational booklets, shared-decision making tools, telehealth and telemedicine. Teaching is one of Lupe's passions. She is an outstanding lecturer and is invited to speak frequently at national and international meetings. She has a talent to make difficult concepts appear easier, and the level of enthusiasm she displays captivates her audiences. She received one of the most prestigious teaching awards at Yale, given by the medical students, and has given multiple named lectureships, prominently the Telfer Reynolds USC lectureship and the Hugh Butt award at the Mayo Clinic. Her enthusiasm for mentoring junior researchers has similarly drawn a number of individuals to perform research under her direction, including Puneeta Tandon, Annalisa Berzigotti and Salvador Augustin. Also while working in the laboratory of Roberto Groszmann, Reiner Wiest, Alexander Zipprich, and Cristina Ripoll met Lupe and they developed a scientific relationship that led to collaborations which have resulted in several publications. Lupe was proud to become a member of the American Association for the Study of Liver Diseases (AASLD) in 1985 and since then has provided invaluable service to the organization in many different roles. She started by being an abstract reviewer for the portal hypertension section in 1990-1991, and has been in constant service since then as a member of the clinical committee (1992-1995), a member and then chair of the membership committee (1995-2002); chair of the portal hypertension abstract committee (1996-2002, 2007) and a member of the nominating committee (2000 and 2003). Her first position in the AASLD governing board was as Secretary from 2004 to 2006 and she has been on the governing board since 2008 when she was elected as councilor. With all this experience she has become knowledgeable about the association and her love and respect for it have grown. Lupe has found the AASLD presidency to be the best "job" she ever had. Although challenging and full of many unpredictable events, the support of an incredible staff and governing board has made it an exciting and enjoyable job. She has strived to follow the strategic goals of the association, to take into account the different interests of its constituents, providing them with opportunities for career development and lifelong professional growth, world-leading meetings and publications on liver disease that provide the opportunities and resources to communicate and advance research and patient care and authoritative guidelines to manage liver disease. She has supported the goals from her predecessors regarding furthering research and advocating for liver diseases (public policy is something that she has learned through the AASLD) as well as continuing to make The Liver Meeting the best international liver conference. Knowing that, given economic and travel restrictions, not all can attend the meeting, the main educational events at the Liver Meeting are now accessible online through AASLD's new LiverLearning. This will be the platform for future educational initiatives, one of them being an hepatitis C virus curriculum for hepatitis C "treaters" and a pilot educational program geared at providing free education in hepatology in general to frontline providers (within and outside of the United States) to enable them to better manage patients with liver disease. One of the plans is that these online programs could be linked to long-distance mentoring via teleconferencing. This will partially address one of the challenges that she has been taking head on, which is the shortage of qualified physicians that will care for the growing number of patients with liver diseases. Toward this goal she is also trying to recreate for others what she experienced in her early career, which was based on having outstanding mentors and on attending The Liver Meeting. Under her leadership, the membership committee has now been converted into the Membership/Mentorship committee, with the additional charge and appropriate funding to recruit talented medical students and residents to become engaged in hepatology. This year, the first pilot group of select residents will attend The Liver Meeting accompanied by their mentors. Lupe is proud and honored to be the current President of the Association; it is an achievement that goes beyond her wildest dreams. 1 Dr. Garcia-Tsao at a recent gathering with several of her Yale colleagues. From left to right: Michael Nathanson, Guadalupe Garcia-Tsao, Roberto Groszmann, and James Boyer.