When did you decide you wanted a career in medicine?
Somewhere around the third year of medical school, far further along than reason would suggest. At the suggestion of my parents, I had applied (and been accepted) to an accelerated college and medical school program at age 16. I didn’t begin to grasp what it might mean to be a doctor until the 5th year in, once ward rotations began. It’s like Holden Caulfield, in Catcher in the Rye: “How do you know you’re going to do something until you do it?”
Why did you decide to specialise in interventional radiology?
Once ensconced in Radiology residency in San Francisco, I was drawn both to musculoskeletal sports radiology and interventional, both in part due to charismatic mentors. Ultimately that immediate adrenaline thrill of an elegant therapy and extraordinary effect sealed it for me. I was a radiology resident wondering which path to take. One midnight, I was assisting a senior resident perform an emergency bronchial embolization at San Francisco General Hospital. At the time, it was just the two of us, no microcatheter, no attending, and cut films. The patient bleeding badly enough that he was self-suctioning blood from his mouth, like at a dentist office. The senior resident placed some Gianturco coils in a bronchial artery — ancient technology by today’s standards — the patient took the suction catheter out of his mouth and abruptly announced that the bleeding has stopped and that he felt better. That kind of experience can really imprint you.
Who have been your greatest influences?
My mother is a nurse practitioner and my father an electrical engineer. He knew that medicine could suit me better than math and engineering, presumably after years of helping me with geometry and word problems. My mother, a nurse practitioner, has always modelled a devotion to patient care, compassion, and a work ethic that I would only hope to mimic. She’s still a workaholic.
In medical school, I was bound headlong for a career in internal medicine, working in underserved areas. The excitement of Boston City Hospital, the ability to impact large populations with unmet needs was thrilling to me; it gave me a sense of purpose and membership in a shared vision. I took a year off and spent time working in primary care in a remote East Africa clinic and hospital. In 1984, I was on a CCU rotation at a Philadelphia inner city hospital when a car drove up onto the sidewalk and struck me in front of a MacDonald’s. Ironically, I was on my way to the cinema to see “The Man Who Knew Too Much.” I missed my date and the movie. My leg injuries forced me to take a year’s break from medical school. I was still walking slowly, so I returned through what I imagined would be a drive-by, sit-down paediatric radiology rotation with Dr John O’Connor at Boston University. I had no idea that this charismatic role model would change my whole career view in one month. That’s what role models and mentors do.
At the University of California, in San Francisco, every division was filled with rock star attendings. Like many other lucky interventional radiologists, I trained with Dr Ernest Ring. It was his leadership and guidance that moved me into interventional radiology and in continuing ways has affected and directed my career. Once in fellowship, Drs Ring, Roy Gordon, and Jeanne LaBerge all influenced me. The roots of much of what I do are traced back to UCSF — certainly my interest in complex portal hypertension. Past that, I had the good fortune of having Constantin Cope as a partner for many years at the University of Pennsylvania. We often sparred about method and action, but this always spurred ideas. Over time, we probably equilibrated each other more than we would admit.
In your professional career, what have been your proudest moments?
I’ve drawn satisfaction from many sources: first publications, handing my first book to my parents, watching fellows I’ve trained grow to become great interventional radiologists. Becoming a fellow at UCSF, then become at Fellow of the SIR. There are many patients, hundreds of patients, certain therapeutic triumphs, procedures that were novel, for which I’ve been proud. Certainly, working on the SIR Annual Meeting Committee and chairing the SIR Annual Meeting was an amazing highlight.
How has interventional radiology evolved since you began your career?
There are so many diseases that we now treat that I would not have imagined — areas that are new or rejuvenated. Some trends: we have matured from a diagnostic into a primarily therapeutic subspecialty. We have differentiated our expertise into an extraordinary variety of areas: arterial, PAD, haemodialysis, cosmetic, oncologic, hepatobiliary, gynecologic, etc subspecialists, etc. For example, I see interventionalists gaining mini-surgical skills, like making anastomoses. The interventional radiologist who can and will aim to be world class at all, our paradigm until now and a badge many of us still wear, could become the dinosaur.
We have developed into true direct referral specialists, ones viewed by patients and non radiology physicians as experts and colleagues. They view us on par, as they well should, as any clinician they would see, be they oncologists, gynecologists, vascular specialists, etc. For the many years, I’ve had reserved booked beds in hospital specifically for admission of IR patients. I run a clinic where I see new patients, dictate letters, even pick up a few heart murmurs, and follow ongoing ones like any internist or surgeon would. Those of us who don’t already do this, will. The most interesting things that we do used to come solely from within the hospital; now, for many of us, the most challenging daily work comes from our clinics.
In which areas have you seen the most change?
Vascular disease, embolization and oncology. Down, Up, Up, invert and repeat.
What do you think are the current problems/challenges facing interventional radiology?
It remains hard to explain to people what we do, be they patients, physicians, or hospital administrators — I’ve taken to describing IR as an advanced surgical practice that happens to live within radiology. That tends to focus our service needs for hospital leaders.
We have real challenges in improving the evidence base upon which we make decisions and claims. The era of uncontrolled 200 patient single arm trials needs to be moved into prospective comparative trials where possible, otherwise we are still basing decisions upon feasibility studies. Decisions should be made upon rigorous data collection and analysis. We’ve been nudging or society members to this, trying to train our future generation in clinical trials, and tightening the standards, for example, in CVIR, a journal I co-edit, for accepted publications. This is the Evidence Based Medicine (EBM) standard. Clinical trials are hard, time consuming, lengthy, and cumbersome but they are absolutely necessary to do. Collective mechanisms to leverage our specialty members to participate in them could prove useful. We should also learn to take advantage of the different experiences, case mix, and research efforts on interventionalists on a worldwide basis. I think the provinciality of continents of IR limits our global opportunities.
What are your current areas of research?
I have active interest in areas of portal hypertension, dialysis interventions, and deep vein thrombosis. I’ve a strong interest in device development, so I’ve a hand in a number of varied technologies and therapies that might bear fruit…or all come to nothing. Things in oncology, cosmetics, IT, widgets, etc. Maybe I should focus on inventing a snack food.
Outside of medicine, what interests do you have?
Besides hiking with my wife and kids, I’m an avid road bicyclist, skier, and skydiver. Basically anything that goes faster than fast.
