Interview with Dr. Phillip Levy

Phillip Levy, MD, MPH is a tenured Professor at Wayne State University where he currently serves as Assistant Vice President for Translational Sciences and Clinical Research Innovation, and Associate Chair for Research in the Department of Emergency Medicine. He is a Fellow of the American College of Emergency Physicians (ACEP), the American Heart Association (AHA), and the American College of Cardiology (ACC), and a standing member of NIH Cancer, Heart and Sleep Epidemiology (CHSA) study section. Dr. Levy is also President of the Metro Detroit AHA affiliate, the current Chair of the ACC’s Cardiovascular Service Accreditation Management Board, and a member of the ACC’s National Cardiac Data Registry Management Board. Dr. Levy’s research interests center on health disparities related to hypertension and hypertensive heart disease, with a dual focus on acute management and population level cardiovascular disease risk reduction. He has been the Principal Investigator for cardiovascular disease-related grant projects funded by multiple entities, including the Emergency Medicine Foundation, the Robert Wood Johnson Foundation and the NIH/National Institute of Minority Health and Health Disparities, and is currently a co-investigator on grants funded by AHRQ, PCORI, NHLBI and the CDC.

Dr. Garg: Thanks Dr. Levy for doing the interview with us for the ACEP RSI section and you know our readers are usually very enthusiastic about these interviews because they're very, learning for them and for anybody who’s looking for a research or an academic career, particularly a research or scholarly activity type of career.

Dr. Levy: OK.

Dr. Garg: So, my first question is, what prompted you for a research career?

Dr. Levy: I think that It primarily centers on the ability to answer questions that develop in the course of being a physician. So, starting out in our specialty we see a lot of disparities, a lot of different medical conditions right, and some of them you wonder why we do things that we are doing. And when you come up with questions about how to potentially do something better or better understand a disease process or a condition, the only way to really address it is through research. There’s one way to go about this, which is to wait for others to do it, and the other way is to do it yourself. I choose the latter rather than the former.

Dr. Garg: Nice! So, when did that happen - at what stage in your career were you when this happened to you?

Dr. Levy: It happened when I was an intern. I trained at Bellevue NYU and when I was an intern, one of my senior colleges, I think he was a third year at the time, was getting involved in some research related to a new biomarker for intestinal ischemia and asked me if I was interested. I eagerly jumped on board, and although the project didn’t really go anywhere, it led to me becoming more and more interested in designing research and thinking about research. So, it was pretty early-on and by the time I was a third-year I think I had done 7 or 8 IRB submissions and conducted research projects.

Dr. Garg: Wow, that's very impressive and you did all that as a resident?

Dr. Levy: Yeah. As a resident, you know, some of it was to answer questions and some of it was honestly to get some data to present at a conference that was interesting, and some of it really was just an exercise in designing research even though the projects never went anywhere. You know, for instance, at one point we had designed a whole IRB project to do screening for melanoma in the Emergency Department, for which, I wrote the whole protocol, went through the IRB, and it just died down eventually. But you learn a lot just by the process of thinking about research questions and designing projects. That was just the way I took it.

One of the projects was a chart review: There was a conference in Poland that I wanted to go to and the department paid people to go for their conferences if they presented abstracts. So, I said, “hey great, I’ll present an abstract at this conference in Poland.” So, we did an evaluation of presentation of patients with eastern European decent presenting to the Emergency department and we did a chart review just to do some simple descriptive study. It was a little bit of a selfish or a self-motivated interest on that side of it, but the vast majority of the interest in research really bore out of questions related to why we are doing certain things and potential novel approaches. In fact, the initial work that led to my subsequent development of expertise in heart failure and cardiovascular disease was started as resident. I designed a small randomized controlled trial of bolus intravenous nitroglycerin conducted pre-hospital in Romania - that was where I initially had seen the idea of bolus nitroglycerin for acute hypertensive heart failure - and we designed a study and ended up enrolling 40 people and presented the data as an oral abstract at SAEM. That work really launched my subsequent growth and career in cardiovascular disease.

Dr. Garg: Very nice. So, my second question is really a follow up question and just branching out here: The question is - how did you decide, or how your first opportunity for an academic job since you had all that work done during the residency?

Dr. Levy: Yeah so, when I was looking for an academic job I wasn’t sure what or where I wanted to go. I got married while I was a resident. My now ex-wife, but wife at the time, was from Michigan, and she’s still from Michigan, but she wanted to move here, so I came here, and I initially was thinking I would work at a 4-year program. I reached out to University of Michigan and spoke to Dr. Bill Barsan and came and interviewed. When I came out and interviewed, the first thing I actually did was take my rental car from the airport and drive to the Detroit Receiving Hospital because, even though I wasn’t interviewing there, I was always intrigued by urban emergency department care. I met a bunch of people down here and really thought I fit well in this environment. I still went through the interview process at the U of M but was intrigued by the whole thing, so I dropped off my CV and got a follow up phone call from Dr. Brooks Bock, who invited me out for an interview, and then things kind of snowballed from there. My first job was as an assistant program director that provided an inlet into academics. So, a paid position with relief time is what every academic is looking for with their first job, and typically research positions don’t do that unless they are research fellowships, or for individuals who come out with funding or anything that would demonstrate the value in investing in that person as a program director or a chair. So, I started on that and my niche was resident research and scholarly activities. I built a whole set up around maximizing the opportunities for residents to do scholarly activity. At the same time, I started building up my own research career and got an EMF grant within a few months of becoming a new faculty member, and that sprung into everything else. Once I got the first grant everything else kind of escalated from there. And then probably, I don’t know 5 years later or so, I transitioned from being in the residency leadership to being in the research leadership and then thing just kept growing.

Dr. Garg: Nice, so I think you kind of answered my other question but I’m going to dwell more on that: so, you said you got your first EMF grant soon after you joined as an attending. How was that experience? Like how many attempts to get your first grant? How was the grantsmanship ruled?

Dr. Levy: Well, fortunately it only took the one try because we got funding on the first submission but the way we did it, there was a senior colleague of mine here who went in as the PI. I went in as a co-investigator, even though it was my project, and really from a grantsmanship perspective just to kind of show that we had more senior guidance for this because it was a single arm study. This was my initial bolus nitroglycerin study that got funded and subsequently was published, although I'll get into that in a second because that's a little bit of an interesting story, but the grant process went pretty smoothly. I didn't quite understand a lot of the nuances of writing a grant, or more importantly the administrative side of grant submission and grant maintenance, but I learned a lot of that during the process.

From there, I was just really bit by the grant writing bug in a weird sort of way and started to enjoy writing grants. At this point I think I've written as PI or Co-I probably about 130 grants or so. I update my CV pretty regularly that's another sort of academic trick right there is the more you keep on top of your CV. The more you keep on top of your CV, the easier it is to keep track of stuff, but It's sort of all built up from that initial thing. You know, that funny story with all of that is that we finished the data and had some interesting results but when I wrote it up to submit to Annals, and it got rejected the first time.  I petitioned them to reconsider and one of the reasons they rejected it was because they didn't really think that it was necessarily safe to be publishing data on giving high doses of nitroglycerin to patients for acute heart failure and so they had some concerns about doing that.

I worked with them to really highlight the innovation and novelty of this approach to heart failure care and that really led to the rest of my career - not the discussion with Annals, but this idea that we’re innovators of heart failure care, specifically the hypertensive phenotype, which led to another EMF grant that got funded but actually never got conducted. It was a comparison of Nesiritide to high dose nitroglycerin, but that was a time when the Nesiritide was facing a lot of scrutiny, so we didn't end up conducting the study. And then from there, I got in roads with a lot of different clinical trials related to heart failure care, and got involved a lot of work with drug development and pharma related to heart failure care, but at the same time, it really triggered what's become my career work, which is focusing on high blood pressure and its relationship to early heart disease – real peeling layers of the onion stuff. So yeah, we're really interested in not only to treat acute heart failure, it's pretty cool that we have developed expertise in this area, but more importantly, trying to understand why we had a bunch of 40 and 50-year olds with advanced heart failure when the national average is 20 to 30 years older. So, it triggered a whole pathway of looking at hypertension and its impact on subclinical heart disease. Population level efforts to reduce the impact of hypertension has become the bigger thing I am focused on especially the role that emergency departments can play in that. Again, not focusing on managing acute complications or the acute manifestations of illness, but really saying 140 million or so emergency department visits a year, with an admission rate that has remained relatively constant at a 13 to 15 percent, that means there's 85 plus percent of patients they come through the ER that have some opportunity to potentially address chronic issues for more preventative health measures: that really has become my most important life work.

Dr. Garg: Nice so that's an amazing story so I'm going to ask you a follow-up question on that: so, my understanding is that you didn't have a traditional pathway of research fellowship and then going into the research career, right?

Dr. Levy: Right, so I didn't do that. Instead, soon after I got my first grant, I recognized the need to get an advanced degree, perhaps somewhat for the training aspect of it, but somewhat for the “letters” aspect too, because having an MPH or MS tells people you are serious. A couple of years after I got to Wayne State, and after I had a couple of grants under my belt,  that process proved really invaluable for my growth because not only did it help me think about this idea of population health, it also gave me a lot of the skill set and understanding of things like behavioral influences and social determinants, which have influenced a lot of my current and past work. And I think while it's important to get training with the research fellowship, it doesn't mean you need a research fellowship to do research. I think what you really need is the willingness to learn, and more than anything, you need mentors. And so the key value of a research fellowship is the mentorship that comes with it – along with some of the class work and formal education. But it is really understanding the process that's critically important. Statistical knowledge base that comes with advanced training is again critical, but the most important thing is the mentorship because you can have all that knowledge and still fail if you don't have the people that can guide you in the right direction.

Dr. Garg: Excellent. So, my next question, which is the second to last question, is so I understand you have been at the same place since that right?

Dr. Levy: I have been here since residency. I went to the University of Pennsylvania for undergrad, then I went to New York Medical College for medical school, and then NYU Bellevue for residency, and got out of residency. My first, and only job, was at Wayne State receiving and I've been here the whole time.

Dr. Garg: So, I can only imagine from time to time you must have negotiated when you have advanced in the different roles. When it comes to a research career, what are some of the negotiation tips or points a person who is looking for a research career should keep in mind?

Dr. Levy: Well the easiest thing to leverage is success, right? So, just because you do work doesn't mean you deserve a raise or more release time or anything like that. And success can be the submission of the grant or manuscripts, or obviously can be the funding and acceptance of grants and manuscripts, but it takes a lot of dedication and time to build up to that. It takes a lot of staying up till 2:00 or 3:00 o'clock in the morning to do work. You know, I was just thinking about this yesterday because I'm now in the position as assistant vice president for Wayne State University - I oversee translation of science and clinical research innovation for the University. I'm also associate chair of my Department. I also do a lot of work with the state of Michigan and I'm recognized as a state leader for cardiovascular disease risk reduction and prevention efforts and have CDC funded projects with them. My team and I have now established ourselves as “go-to” people, but it all begins with that hard work. I think a lot of people expect the time before the deliverable is done - meaning they want to be appreciated for work that has yet to come.

To me, the most important thing is that people should just pull up their socks and work hard, and once you do that, people recognize. Along those lines, once people start to recognize, people start to ask you to do things and they will also want to recruit you. That has happened to me throughout my career, and what has happened each time that I’ve been recruited somewhere else- I have leveraged that into some form of retention.

Initially, it was just some additional release time and new titles. Overt time, it became more money and investment in the research enterprise I'm building. It depends on the point you're at in your career, what you need to have to be comfortable in your skin and your role. I had been recruited early on after I had some grant success and leveraged that into what I felt I needed at the time, which was diminished clinical obligation and additional compensation to offset the diminished clinical time. Our group is a little bit weird - we have 2 separate pay pathways: one is from the University and one is from the practice group, and the practice group only pays for clinical work, they don't pay for the academic time; so in order to work less and maintain the same income, you have to increase the academic stipend. However, when you have grants it makes it a lot easier to ask for more dollars in your academic stipend as you are covering a portion of your salary.

And I think that's an important goal for people to think about because at the end of the day, chairs who make these decisions and deans who support them have a dollar issue they have to deal with. So, if you are covering portions of your salary and are covering members of your team and with those types of things it's a lot easier to negotiate when you're in a position of strength. I would say that probably the point that I gained the most interest in being recruited was after getting my first NIH grant - getting an R01 makes people start to look as there's only so many of those in our specialty and people who get them are definitely a commodity in our field. We just do not have the research workforce, if you will. So, researchers who are grant successful, are going to be commodities and it's important to know your value, and your value is really dependent on your track record, and where you are in your career trajectory. If someone is looking to transition from assistant to an associate level, getting more release time is a key feature in order to be able to generate more productivity. If you're looking at associate to professor level, you can leverage potentially an appointment or a promotion. Also, you can leverage titles, but really what most people want is the support for their research mission and so understanding that part of retention or recruitment, whichever way you want to look at it, is to know what you need to be successful and, especially if you're going to move to a new place, what the expectations are of you. A key then is how to make sure you get compensated appropriately while setting yourself up for success by building into your package the pieces that are needed like research directors, operations directors, research personnel, statistical support time, travel, equipment, whatever it might be.

Dr. Garg: Thanks, that was great advice. My last question is really open ended - it's really something you want to communicate with the section: any advice you would give to three levels of career - young, mid-career, and senior members.

Dr. Levy: Well, I think the most important advice for all levels is first and foremost, do what you love. So, the research you pursue should be something that matters to you. It's easy early on, particularly for those who had some initial success, to get distracted by multiple different projects, and if you're a good writer, I would say for most people they are not good writers honestly, making sure that you become a good writer by doing it more and working with people who take the time, not only to revise your work, but also to help you understand why they revised it the way they did just so that you don't make those mistakes again in the future. That is critical to success. Doing an MPH or getting a Masters in Science, are really valuable as well. A lot of people like to pursue MS because it gives them the statistical knowledge, but I think the MPH is equally useful if not more valuable because it forces you to learn how to write!

While these pieces are key, knowing where you are going with such efforts and finding out what your niche is and the area you want to emphasize is paramount - from there you can build things methodically to establish both your content expertise internally and externally, as well as your credibility, in the research space. A lot of times you can craft your narrative - I've work with my junior faculty numbers on this a lot. Start out by doing a literature search and a review article on the topic and identify gaps that you can build upon as you develop content expertise areas. Design a small pilot project and publish that, and then keep building up your track record to show not only that you are truly an expert in the area, but that you're also collaborative, co-publishing with the people you want to work with.

That's another thing that often gets overlooked - I think the idea that people are lone wolves, and they need to get out there and sort of not be as collaborative to establish themselves. The days of the independent investigator are behind us and we are in an era of team science. The best thing you could do to both grow your writing skills as well as to grow your portfolio of publications, is work with as many people as possible within your area. That doesn't mean work with people that are going to distract you from what you're trying to strive towards. This has happened a lot in the acute heart failure world. Sean Collins, Peter Pang, and myself with Frank Peacock, Deb Diercks and some others along the way have published a ton together. We all started out as junior faculty members trying to make a name for ourselves but at no point did we see that as competition. Rather, we saw we saw that as a strength - let's all get together and we're stronger together than we are separate. So, I think that's another really important lesson is don't fear the collaboration. In fact, espouse it and grow with it as opposed to being afraid of it.

I would also say a career development plan, be it 5 or 10 years in the future, is so important as it helps shape whatever you want to, particularly for associate and assistant professors because it's a grounding mechanism. Start at year 5 with what you want to do, and then work backwards with what you need to do in the next 2 to 3 years, and the next 6 months to a year. It can be just “I got to publish the data that I'm sitting on” and then move forward, or at the same time, you might want to drive towards a grant to do specific work in the area to make sure you're building up that portfolio that's going to show the grant reviewer that you are worth investing in.

Another one pearl is that you are always going to a mentor even when you get higher and higher in your career. You're always going to want people you can go to for guidance and advice. There are different types of mentors, and not every mentor is right for the same thing. I have people who I go to every time I get recruited somewhere. I go back to my old residency director Eric Legome, still one of my best buds, and I always talk to him about the opportunities and he helps me weigh the decision. I don't go to him for research guidance or advice because he can't help me in that way. I have people in other departments and disciplines that I work with as well for mentorship and career guidance. If it's not in your institution, it’s OK. You could find it elsewhere. But once you find it, cherish those relationships because they're valuable and then pay it forward as well, making sure you’re there for people behind you who need the knowledge on the expertise that you’ve gained overtime.

It is an evolution, right? in the beginning when you're an assistant professor it's about first author publication and about expanding your grant portfolio, having unique data and something important to say, and working with others in getting your name recognized.

As an associate professor, it's a little bit of that and more of “now I'm starting to pull other people along and I'm teaching people and mentoring people”. I'm transitioning from the first author to the last author and then when you're a full professor, it's about doing big things but also making sure that you are creating an environment for others to be successful within. As you keep moving forward at the professor level it becomes less about the self, and more about the collective.

Dr. Garg: That's great. That's an amazing description you gave. So, I really, really, want to thank you for the time and all the advice that's particularly very learning for me, and I've always learned from you.