Introducing Norah Terrault, MD, MPH, Our 2023 AASLD President

It is our privilege and pleasure to introduce Norah Terrault, the 74th president of the AASLD. Norah is a truly remarkable woman whose depth of intellect, passion, and kindness embodies the spirit of our society and its members. Having known Norah for over 2 decades as our mentor (Lai) and mentee (Peters), we take great pride in telling you about her personal history and professional accomplishments. BACKGROUND AND TRAINING She was born one of 8 children and grew up on a farm (“cattle, turkeys, and lots of chickens”), north of Edmonton, Canada. Her family embodied hard work without complaint—“just do it” was their motto. Her father did not finish high school and her mother dropped out of nursing school to care for her own mother. But her parents instilled in their children a love of learning and encouraged them to pursue formal education. Norah went to a small school in a small town, graduating high school as valedictorian. She then attended the University of Alberta where her horizons broadened, meeting people from varied backgrounds, which inspired her to “aim high.” Although she took pre-med classes, she initially became a social worker for 3 years where she met her life partner Rom. She loved making a difference in people’s lives and decided to become a physician to do more. She completed her internship/residency and gastroenterology fellowship at the University of Toronto. There, she met Jenny Heathcote who was the most influential person in her early career, both as a role model and the one who excited her about hepatology and gave her the chance to explore other opportunities. After training with Victor Feinman and Chris Pappas, Jenny introduced her to Bruce Scharschmidt, and off she went to the University of San Francisco (UCSF) as a research fellow on a Canadian Liver Foundation Award, training with Teresa Wright. It was during this time that she also obtained a Masters in Public Health at the University of California, Berkeley. Armed with these exceptional credentials, she was invited onto faculty at UCSF in 1997. “I credit my early career mentors, John Roberts (liver transplant surgeon) and Marion Peters, for helping me navigate funding and balancing clinical work and research which allowed me to establish myself at UCSF in those early years.” She stayed at UCSF until 2019, serving as the Director of the Viral Hepatitis Center and the Transplant Hepatology Fellowship Program Director. In 2019, she assumed the position as the Chief of the Division of Gastroenterology at the University of Southern California (USC). SCIENTIFIC CONTRIBUTIONS Norah’s scientific accomplishments embody every aspect of AASLD’s mission “to advance and disseminate science and practice of hepatology, and to promote liver health and quality patient care.” In toto, Norah has authored over 400 peer-reviewed manuscripts, editorials, and invited reviews, as well as US national guidelines for treatment of HBV, chronic hepatitis C (HCV), and reproductive health. A word cloud generated from the titles of her published papers illustrates both the breadth and the focus of her scientific work (Figure 1). Specifically, Norah has focused her research activities on viral hepatitis and, more recently, on NAFLD, with a specific spotlight on patients with cirrhosis and liver transplant recipients. In addition to multiple clinical trials related to preventing and treating chronic hepatitis, viral hepatitis, and fatty liver, Norah has been PI on multiple NIH-funded studies, including the current NIH-supported HBV Clinical Research Network (HBRN), NASH Clinical Research Network (CRN), and Liver Cirrhosis Network (LCN).FIGURE 1: The word cloud generated from the titles of Dr. Terrault’s published papers illustrates both the breadth and focus of her scientific work.Among her many contributions, Norah has studied the role of race/ethnicity and sex in the prevalence of chronic liver disease and in the natural history and risk of cirrhosis and liver cancer. Her group was among the first to show that fatty liver among North Americans is associated with lower body mass index in persons of Asian descent compared with other racial groups, and that individuals who identify as African-American had a low prevalence of fatty liver despite high body mass index and other metabolic risk factors. Her work also highlighted the lower risk of progression to cirrhosis but higher risk of HCC among African-Americans with chronic HCV, the higher risk of fatty liver among “lean” Asian-Americans, and the key importance of race in predicting risk of HCC. She has studied ways to minimize morbidity and mortality related to chronic HCV infection, by identifying modifiable risk factors such as adverse effects of daily cannabis use, and the importance negative contribution of concurrent hepatic steatosis. Norah’s group was also the first to highlight differences in HCV outcomes after liver transplant by recipient sex and donor race and most recently that viral hepatitis awareness varies by race/ethnicity. She has contributed to a growing literature highlighting the important differences in liver-related complications between men and women, including the impact of gender on access to liver transplantation. By “shining the light” on these differences, management strategies can be tailored by risk profile to improve overall short-term and long-term outcomes. She has collaborated on studies which highlighted disparities in transplantation related to with obesity, alcohol use disorder, HIV, and immigrants. Through consortia activities with the NASH CRN and Coronary Artery Risk Development in Young Adults (CARDIA), she has focused on determinants of fatty liver and its natural history. Of particular interest is the influence of alcohol use on metabolic fatty liver disease and vice versa. Alcoholic hepatitis is a controversial indication for liver transplantation. Through a multicenter consortium that Norah established (ACCLERATE-AH), they have evaluated the outcomes of patients undergoing liver transplantation for alcohol-associated hepatitis, evaluated predictors of return to harmful alcohol use posttransplant, and developed predictor score and models to help inform the selection of candidates, management posttransplant, and national policy. Norah’s research contributions extend well beyond specific scientific content of her papers. She is acknowledged as a leading world investigator in liver disease and the “go-to” person for research studies, advice, and international meetings of viral hepatitis and liver transplantation. She is an outstanding writer and editor. We have both been coauthors on manuscripts with Norah and they always come back exponentially better after she has “reworked” them. FROM THE CLINIC TO THE CLASSROOM TO KUDOS Norah is universally respected as a clinician by her colleagues and is equally beloved by her patients. No matter how busy her clinic is and how many other commitments she has, she makes her patients feel like they are the only patient she has to see that day. This devotion to improving her patients’ care, along with her excellent clinical acumen, has been the “secret sauce” to identifying key unmet needs that are relevant to patient care to yield impactful areas of research. Teaching has been a first love for Norah, and she has continued to teach throughout her career. Whether it be one-on-one or in a large lecture hall, Norah is a superb teacher. Of her teaching style, former student and mentee Carla Coffin commented, “Whether it was teaching fellows or at a major conference, I always try to model Norah’s lectures in style and clarity.” Since 1999, she has actively engaged in teaching to medical students, house staff, and fellows. Her legacy as a teacher is also apparent through her curriculum development. At UCSF, she developed and taught the Transplant Hepatology fellows curriculum. She established the HCV Extension for Community Healthcare Outcomes (ECHO) site at UCSF and at USC, where she taught educational modules to community providers. She has created courses in liver disease and transplantation and lectured throughout the world. In addition to being the first recipient of the Jan Albrecht Commitment to Clinical Research Award, Norah has received multiple other awards including Dr. Saul Krugman Career Development Award from Hepatitis Foundation International and Mentor for International Liver Transplantation Society Rising Star Award. In 2021, she received the prestigious Gold Medal Award from the Canadian Association for the Study of Liver Diseases. CONTRIBUTIONS TO MENTORSHIP AND RESEARCH Norah’s contributions to the hepatology field in the form of mentorship parallels her enormous contributions to science, patient care, and teaching. The value of her mentorship is well-represented by her numerous mentees who have become scientific leaders themselves within multiple domains including (but not limited to) viral hepatitis, liver transplant outcomes, alcohol-associated liver disease, NAFLD, and pregnancy in liver disease. More than 90% of her mentees remain in academic positions, a truly remarkable outcome and evidence of how she mentors and whom she attracts to mentor. She says she is “blessed that my path crossed with theirs. My mentees are innovative, creative, and shining.” Norah has a remarkable ability to support mentees conducting high-impact research across the spectrum of translational science—from patients to practice to population health. As evidence of the breadth of her mentoring skills, her mentees’ publications cover topics ranging from molecular characterization of HBV reservoirs to sex differences in liver transplant outcomes to improving the hepatitis C care cascade during pregnancy. I (Lai) have been one of the lucky many who have had the privilege of calling Norah my mentor. Of the many skills that I learned from Norah, perhaps the most important one was how to ask research questions that matter. It was Norah who taught me how to transform real-life gaps in clinical care into answerable research questions. But perhaps more importantly, it was Norah who taught me how to fill those gaps through effective dissemination of research findings, bringing research back to the bedside to improve care for patients. This is a skill that is common among Norah’s mentees and what I consider is one of her greatest legacies as a mentor. Another key feature of Norah’s success as a mentor is her ability to make her mentees feel seen and heard. From Jennifer Flemming: “She was 100% present in the moment. As a mentee you always felt as though what that you had to say was important, and she was not distracted by any outside influences.” Brian Lee commented, “I’ve never seen so many overlapping boxes on a schedule than hers, but she’ll always make time for her mentees.” We would be remiss if we did not acknowledge her role in inspiring women in hepatology to become leaders in medicine. It is no accident that the women Norah have mentored have ascended the ranks to become chiefs, medical directors, educational leaders, research directors, journal editors, and hospital administration leaders. During a recent conversation in which I (Lai) sought her guidance about taking a leadership position, she reflected, “If women don’t make up 50% of the division chiefs, then how are we going to make up 50% of the department chairs?” Norah taught me—and many other women mentees I spoke to—to pursue goals that are big, bold, and ambitious, not just for ourselves but to be in a place where we can support other women. Although she is only the sixth woman to serve as AASLD President since the founding of the AASLD in 1950, her mentorship of women in particular has paved the way to ensure that there will be equal numbers of women as men in hepatology who have been inspired by her to lead our society. PERSONAL PURSUITS Norah loves to travel. Whether it is for professional engagements or personal pursuits, there is no place on earth she won’t visit. Both at home and abroad, she enjoys outdoor activities, particularly hiking and cycling. She would even brave the San Francisco fog and hills on occasion to bike to work during her time at UCSF. Her partner, Rom, is dedicated to the arts and music, and they enjoy dancing—anyone who has seen Norah at liver events can attest to this. Having trained in classical piano, she enjoys music and has picked up piano again with a new keyboard that Rom bought her during COVID. We’ve been lobbying for her to showcase her piano talents at the gala at The Liver Meeting 2023! NORAH’S VISION FOR HER TIME AS AASLD PRESIDENT Norah’s career path is one of many firsts: from college to research awards to her representing the pinnacle of research, teaching, patient care, and mentorship. Her first manuscript was on interferon therapy in recurrent HBV after liver transplantation. So it is fitting that one of her major goals is to see a “first” in hepatitis B, using her platform in AASLD to push the envelope of new drugs for a HBV cure, while continuing public health efforts to eliminate HCV and HBV. True to her last 2 decades of her career, she will continue to promote young talent and the next generation of “firsts” within the AASLD. She sees the AASLD as an “open tent for new faces, including young investigators, hepatologists, scientists, patients, and allied health professionals who see the AASLD as their home and allow them to flourish.” There is no doubt of the incredible effort that she will continue to dedicate to advance and innovate within the AASLD, ensuring that the AASLD will continue to make a difference. CONCLUSION One piece of advice that Norah passed on to her mentees (Carla Coffin) was “Be kind and work hard.” We cannot think of a better way to summarize the impact that Norah will have as AASLD president. She will work tirelessly to ensure that the AASLD continues to fulfill its mission and get closer to its vision “To prevent and cure liver diseases.” And she will do so with kindness and warmth that continues to bring our great members together as a community. Norah, we are proud to call you our colleague, collaborator, friend—and now, our president.

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