Transcript of the February 2024 Arroyo/“ASCI Perspectives” video

Interview with Juan Pablo Arroyo, MD, PhD, Vanderbilt University Medical Center (recipient, 2022 ASCI Emerging Generation Award)
Interviewed by Jennifer S. Yu, MD, PhD (elected 20218); member, ASCI Diversity, Equity, and Inclusion Committee

Note: The text has been edited for readability by ASCI staff.

Jennifer S. Yu: Good afternoon and welcome to the ASCI Perspectives. I am Dr. Jennifer Yu from the Cleveland Clinic, and today my guest is Dr. Juan Pablo Arroyo. Dr. Arroyo is an Assistant Professor of Medicine at Vanderbilt University. His research has focused on understanding fluid dynamics and their regulation of metabolic diseases. Dr. Arroyo is a recipient of the ASCI Emerging-Generation Award in 2022. He is also the recipient of the 2020 Robert Wood Johnson Foundation Amos Faculty Development Scholar award. Dr. Arroyo, thank you for taking the time to speak with us today and sharing your words of wisdom.

Juan Pablo Arroyo: Thanks so much for the invitation. I’m really happy to be here.

JSY: You had an interesting path to becoming a physician-scientist. You obtained your MD at the Universidad La Salle in Mexico and followed that up with a PhD. Was there something in particular that attracted you to this career path?

JPA: I’ve been a little bit of bouncing around. I started medical school in Mexico. You just do six and a half years straight out of high school. And I met my physiology professor — he’s a basic scientist, and he basically taught me to love physiology. And once I finished my MD, I was dead set on becoming a surgeon in the US because of some rotations that I had. And I had a required year of research that I was doing, and I was in his lab and I just loved it. So I ended up getting a PhD in kidney physiology. And it was basically for the love of understanding why things happen the way they do, more so the diseases; it was understanding how the body works. Never second-guessed the surgeon part. And I ended up doing so: I did the MD, then I did the PhD. And then I got a prelim position as a general surgery resident at Yale. I did a year there, and after that I realized surgery was definitely not for me. So I ended up doing a two-year postdoc in renal genetics and hypertension in Rick Lifton’s lab. And that was an amazing experience that taught me an enormous amount.

And after that I came to Vanderbilt, where I’m at, and I did the physician-scientist training program. So I did two years of internal medicine, the year of clinical nephrology, and then I was asked to be a chief resident. I was a chief resident for a year, then went back into the lab, started research, and then got promoted to faculty. So it’s been a little bit of a circuitous path to get to where I am now.

JSY: Wonderful. And it really speaks to how teachers can be so inspiring to students and how they can really change your trajectory.

JPA: Oh, 100%.

JSY: And I’m so glad you followed your heart and decided what was most important to you and most interesting to you. So let’s hear a little bit about your research. Our bodies are comprised largely of water, and your research focuses on water dynamics and links to metabolic diseases. Can you tell us a little bit more?

JPA: So when I was a surgery resident, I was on the thoracic surgery service. And a clinical observation was that a lot of the patients undergoing thoracic surgery that didn’t have any preexisting conditions — they were going for a wide resection or some . . . it’s major surgery, but they were going for surgery, And I was told as the intern that I had to keep them negative. So I had to give them Lasix and make sure that they didn’t stay . . . their eyes and nose weren’t positive. I was fresh out of my PhD, and I was like, “Why am I giving these people Lasix?” And it always bugged me that we were given the diuretics, and I didn’t understand the physiology: Why were these people producing antidiuretic hormone? Because that’s the problem. If you don’t give them diuretics, then they can develop hyponatremia, low serum sodium. And that sort of stuck with me: Why is this happening? Why is this happening?

And then I kept asking the question “Could the vasopressin be coming from somewhere else, not just the brain?” Because the explanation has been like, “Oh, everybody gets . . . the body gets stressed, and the hypothalamus produces the vasopressin.” I’m like, “I don’t know if that works out.” And I continued to follow that. And then when I came to Vanderbilt and was studying nephrology landed on polycystic kidney disease and realized, “Well, they have high vasopressin levels as well, and this is driving disease — is this all coming from the hypothalamus?” So then I started on my research, and my research career has been built initially on understanding how vasopressin works and showing that vasopressin is not just made by the brain. We were lucky enough to publish in JCI insight in 2022 that vasopressin is made in the kidney. So functional vasopressin is coming from the kidney.

The physiological relevance is what we’re working on now. But that goes to show that . . . what we’re interested in is that if each cell has the ability to regulate its own water metabolism, and water metabolism is intimately linked to glucose regulation and fat metabolism and bioenergetics, then is there anything else that we’re missing in terms of understanding how water can change our internal environment? So that’s the current focus of the lab. And again: a circuitous route to get to where we are now. But I’m incredibly excited about the work that we’re doing.

JSY: How fascinating. Well, thank you for sharing how you came upon that — just asking questions of patients in your patient care and how that really led to your research in vasopressin. Many people are working to reduce bias in the workplace, and you have advocated to eliminate the requirement of applicants to provide their pictures in their ERAS [Electronic Residency Application Service] application for residencies. Can you expand on that?

JPA: So initially I got the opportunity to be a chief resident for the Vanderbilt Internal Medicine program. And we were doing a lot of these interviews, and this was I think 2018 to 2019. And this was — we were doing in-person interviews and reviewing the files. And initially when we were reviewing the files, the way that you download the ERAS documents, the first thing that would pop up was a picture. And I would find that when we were doing evaluations, the first thing you see is the picture. And that to me just sends the . . . you have a preconceived notion of what this person is or isn’t. And I started looking into some of the data, and there’s actually data that the picture can definitely bias how you see an application.

So what we decided to do is, we came up with a more comprehensive system to evaluate applicants. We have a pretty thorough spreadsheet, like a data set that we go through and we evaluate on multiple levels. And we eliminated some of the test scores and we focus on who this person is and what their trajectory this far has been. And the whole point was trying to evaluate everybody the same way. So eliminate bias in either direction and making sure that we’re evaluating the best people for the job regardless of any other factors. So that’s encouraging.

JSY: That’s great to hear. Do you know if other institutions have also rolled out a similar policy not to look at those pictures?

JPA: I know that some do. I think it’s relatively informal so far. Some people, some institutions have been doing it for a while, and others have started adopting it. I don’t know of any formal mandate to do it, which is why we wrote that letter to the editor that got published in Academic Medicine calling for ERAS to just: let’s just do this nationwide. Because again, it’s not about highlighting someone and pushing someone else down. Just basically leveling the playing field for everybody, making sure that the attributes that we care about for physicians are the ones that are highlighted when someone’s applying for an interview. So: Not formally, but hopefully we’ll get there.

JSY: Yeah, well it’s a big step in the right direction. Thank you. Can you share with us some words of advice for those perceiving bias, either conscious or unconscious, in the workplace?

JPA: My own experience has been . . . What has worked for me is I always try to assume that everybody is doing the best they can with what they have. Period. If someone is upset for a particular reason, and yelling is what they can, then that’s the best they can do with the emotional, psychological tools and everything that they have right then and there. So me coming from the position that that is the best I can get from that person right here and right now leads me to then treat everybody with more kindness and respect. Because I don’t automatically assume that they’re out to get me. Because I think that starting there makes everything a little bit harder. So just assuming that whatever reaction is the best that that person can give you right then and there makes everything a little bit easier.

JSY: Great. I really like how you say you treat everyone with kindness — kindness and respect — which is easier said than done sometimes, but great.

JPA: Yeah, definitely. I mean, I can tell you that because of my last name. So I have four names, and something that we are discussing, right? My name is, John Paul — in Spanish, Juan Pablo — and I have two last names, my mom and my dad, Arroyo Ornelas. So my full name is Juan Pablo Arroyo Ornelas. So sometimes when I’m seeing patients, they’ll look at my name and they’re like, “What’s your name? Where are you from? You’re not from” around here.” And I tell them, “No, I’m not. And generally what I — again coming back to this “Treat everybody with kindness” is when I’m meeting a patient, particularly in nephrology, I’m the kind of doctor you don’t want to meet, right? So everybody’s going to be afraid. That’s it. So if they’re scared and I meet the patient when they’re scared, everybody, and this includes myself, everybody tends to be scared of difference. And if there’s something different in a stressful situation, of course, tempers will flare. So again, going back to the “Everybody’s trying the best they can with what they have,” I go back to the patient and I explain, “Yeah, I’m not from around here, this is this.” And I give them a little bit of background. And that always has helped.

JSY: Great. Well, words to live by: treat everyone with kindness. We have many early-career scientists who watch our program. Can you tell us a few words of wisdom, lessons that you’ve learned during your career journey?

JPA: I think one of the biggest lessons that I’ve learned is I thought in the beginning that I needed to have everything figured out and, you’ll hear this a lot, that the trajectory is linear. And you can see, so from my career trajectory, nothing has been linear at all. I started off as wanting to do general surgery or general surgeon in Mexico, and now I’m a nephrologist that’s an academic scientist in Nashville. It’s not linear.

So what I would say is that same kindness that I try to show to others in terms of they’re doing the best they can with what they have, I try to do that with myself. I’m doing the best I can with what I have. And if the best I have right now is, like, the best I can do right now is just sit down in front of the TV and watch a show, because I don’t have the emotional strength to deal with either writing the paper, writing the grants, and I just can’t. And what I can do right now is make the conscious choice of: I’m going to sit down and I’m going to watch a movie with my kids. Okay. That’s what I can give. And that same kindness, sort of bring it on myself. I think that that’s the best advice that I can give, because specific advice in terms of like, “Learn this technique” or “Learn this other thing” or when to apply for a grant — what I’ve realized with myself is that the best thing that I can do is take advantage of the tools that I have to give and that I can bring to the world. Right? So if I’m in a really good place where I can push myself a little bit harder, I will try. And then if I fail, I’m like, “All right, well, I tried.” But again, that same kindness that I try to show to other people reflected on myself.

And I think that we need to learn to deal with failure a lot in science. And from the junior faculty’s perspective, I’m not good with failure, I’m not good with rejection, and I’m always paranoid. I have terrible imposter syndrome. And all I try is like, “I’m going to try my best and be kind with myself every time that I try my best.” And that’s it. That’s the best advice that I can give. Not necessarily field-specific, but just be kind.

JSY: Thank you. That was so important for you to say, to be kind to yourself. And it sounds like you’re very introspective as well, which is really important in our field and in many other fields as well. And you also talked about resiliency, especially as a physician-scientist taking care of sick patients as well. It’s tough. So it’s important to reexamine yourself and step back when you need to. And lean in when you need to. Well, thank you so much for sharing your words of wisdom today, your experience. It’s very informative, and I think will help a lot of our viewers. Thank you.

JPA: No, you’re very welcome. I’m very thankful to have had this opportunity to talk with you and I hope I’m able to help someone with this.

JSY: I’m sure you will be able to — many, many people. Thank you.

JPA: You’re very welcome.