Interventional radiology: past and present

Episode Transcript

Good morning, SIR. I’m Dr. Ziv Haskal, and I am very excited to be in the soundproof podcast booth at Cook Medical today with my extraordinary colleagues and friends, mentors, inspirations: Professor Anne Roberts and Professor John Kaufman. And the three of us are just going to talk about some interventional chat. So, hello, John. How are you?

Ziv, I’m doing great. And our first question is going to be to talk about is: who was your mentor? And I’m going to ask one of my mentors, Anne Roberts, to talk about who her mentors were, because it’s all one long line.

And tell us how you got inspired as well. I mean, what was that light that went off?

Well, for me, I couldn’t decide what I was going to do with my life. So I started off being a history professor or a history major and got a master’s in history and then decided I wanted to go to medical school. And then in medical school I couldn’t decide between OBGYN and radiology. And so I applied to both and got into— did a year of OBGYN before I went into radiology. And when I got to radiology, I really hated it and I thought, “Oh, I’ve made a huge mistake.” And so then I went along and first Peter Mueller took me into a case and he said, “Have you ever done a biliary drainage?” I go, “I don’t even know what a biliary drainage is.” So he said, “Oh, come on.” And so I went in and he started showing me how to stick a needle into a liver. And I was like, “Oh, this is fun. I like this.” So then I went to the very last rotation of my first year, I did angiography and I was there for a day and it was like lightning hit me and I said, “This is what I’m going to do.” And I went in the next day to see Chris Athanasoulis and said to Chris, “I want to do a fellowship in this.” And he looked at me like, who is this woman?

Was there even a fellowship? Was it called that then? Special procedures?

Well it was a– yeah, you did a fellowship after your residency. And he looked at me and like, what do you want? What? And I said, “I want to do a fellowship in this.” And he said, “Uh, why don’t you come back and talk to me at the end of the month?” So at the end of the month, he called me into his office and he said, “Have you decided what you want to do?” And I said, “Yes, this is what I want to do.” He said, “Great, you have a fellowship, just go off and finish your radiology and come back and we’ll train you as a fellow.” So there I was.

That was it. And you were off to the races?

I was off to the races.

That was– it started with the biliary drainage with Peter Mueller?

Peter Mueller, and then Chris Athanasoulis and Art Waltman. And the thing really got out of both Chris and Arthur was they didn’t stand back and be the person who was in charge or whatever. I mean I have a picture of Arthur washing down the floor after a case so that we could get the next case going, and Chris would get patients on a gurney and he and I would push them up to the floor so that we could get the next case going. And they were really inspirational to me because they just got in and did it.

Reminds me of my early days at Boston City Hospital when you’d have to fight for a bed and bring your patients down as well to radiology. John, was there somebody– was there a light that sort of tripped for you?

Yeah, it’s such an interesting parallel. So my father was a radiologist, so that was the last thing I was going to do when I finished med school, interestingly, but slowly realized that maybe radiology was the right thing. He’s pretty smart and I should do that. And I hated it initially. And it wasn’t until I rotated on special procedures with Alan Greenfield at University Hospital, Boston City Hospital, now Boston Medical Center. And the very first day there’s blood all over the place. There’s bile, there’s pus, there’re people coming in and out. These are incredibly smart people doing things to people that I didn’t think you could actually do. Like, legally.

You wanted to be in the wet. You saw that and you said, I want to be in this.

It was like a light bulb went off. I said, “Ah, this is the thing I’ve been looking for.” It’s the combination of all these great things and these great people who are real doctors, who really know what’s going on and they can do these crazy things. So ever since then, it’s just like every day has been like that. And many of the same mentors, Alan, who was originally trained by Arthur Waltman and Chris, who I ended up having the great fortune of working with, and then Fred Keller and Joseph Roche.

I’ve often thought as men that we always, we hate our fathers, we want to be anything other than them. And yet we realize late in life that the best we do is be a paler version of them exactly. And that’s a good thing.

Yeah, I was being a stupid rebellious seventies kid, you know? And Anne is incredibly influential. I think anything I’ve done in SIR is a result of Anne. I don’t know if you remember calling me one day and saying, “I’m putting you on this committee.” I was a junior faculty in Mass General. And I said, “Oh, okay, thank you Dr. Roberts.”

That was Curt Bakal for me, for standards, who turned our field around because of his MPH. I came to this from a very different direction. I was wired and groomed to be an internal medicine doc, and I wanted to work, John Stuart Mill type, the most that I can do for the most people. So I was interviewing at city hospitals everywhere, and I was doing a rotation in Philadelphia and I was going to meet a date on a sidewalk. We were going to see the Hitchcock movie, “The Man Who Knew Too Much.” But at that moment, I hadn’t seen the film otherwise I wouldn’t have been at the corner of broad Allegheny struck by a car, lost a year of school because I had very bad knee injuries. And when I returned I was walking a little rough. So I did a pediatric radiology rotation and Jack O’Connor, the later dean of radiology, made looking at little plastic films, even with this polio arm, the most macho thing that you could do on the planet.

And I was berated by all my medicine interns, “You’re going to sit in the darkroom, you’re going to do these things.” But I said, “I’m going into radiology.” And this was sort of fed and then it was do I want to follow Harry Genant and Clyde Helms and worked in sports and MSK? And then there was Ernie and Roy and Gene and that kind of adrenaline case that said to me, “I want to do this.” Did you have those cases where you saw something that that person doing it did not think was anything other than mundane, but to you turn the light on?

I don’t know if it was one case. I think for me it was just the fact that I could take the imaging—which I loved imaging, I loved pictures— and put it together with taking care of people. And that to me was– absolutely didn’t matter what it was. It could be biliary drainages or it could be embolizations or it could be anything. But it was that combination of imaging and taking care of patients that I just found so powerful.

Yeah. I think it’s being as good as the other clinicians taking care of patients understanding as well as they do the problems they’re dealing with, but having a completely different way of dealing with it and approaching it and solving problems that no one else can solve. And one of the phrases, again, my father said, “You’re the doctor’s doctor when you’re a radiologist.” And when you’re an interventionalist, you solve the problems for everyone in the hospital that no one else can solve. And it’s just this really invigorating, stimulating thing. So is there one particular case? I can’t say there’s one.

I remember a case in San Francisco general hospital of hemoptysis, serious bleeding, Hispanic speaking man. I’m there with the chief resident. This was still an old unit, like a barium, where you would pull the thing across and take four by four films. And that’s what we’re doing. It’s just the chief resident. This man is bleeding enough that he has his own Yankauer suction in his own mouth. And this chief resident deploys two, 3 x 2 millimeter stainless steel Cook coils, which at the time was high tech, through a 6 French or 7 French catheter. And the man stops bleeding, takes it out of his mouth, and says so in Spanish. And it was like a light bulb exploded in my head. And I said, “This is just stunning.” And I’ll share with you something that somebody did generously for me. Just two days ago, a woman came up to me and said, “You may not remember, but I was a med student when you were at University of Maryland, and there was this five-year-old, trauma, had been bleeding for 36 hours. And the readings were delayed and continued to bleed. And then you got involved and you did something, and the kid stopped bleeding and he left the hospital. And that was transformative.” And I said, “I have no recollection of that. Of course not. But I’ve had those same experiences.”

Yeah, well, and I think there’s one thing, and this wasn’t what got me into interventional, but like postpartum bleeding. I mean, these patients come down and they’re going to die because they can’t get the bleeding stopped. They may have even done a hysterectomy, and they’re still bleeding. So here they come down, this is a woman, she’s got a partner, she’s got children, and you’ve saved her life because you’ve stopped her bleeding. And not only have you saved her life, but you’ve saved the lives of her children and her partner because all of a sudden they have a mother and a partner that can take care of the baby that was just born. And that to me is— if there’s one thing that we do, that, for me, is the thing.

So let me pivot a little bit here, because both of you are incredibly inspiring people. Both of you I’ve kind of watched and tried to follow. You each do it in your own way. So I’m really curious, Anne, your perspective on how you inspire people, because you walk in a room and people are just noticing and taking note and trying to listen to what you have to say. How do you do it?

I don’t feel that inspiring. I just think that if you have a passion for something and you can convey that passion, I guess that’s inspirational to people is that you can say, “Wow, this is a great specialty and you should be in it and you should be involved in it. You should get involved in the SIR. You should be there and be at the table and help.” And that to me is really important. And John, come on, you’ve done that a whole lot.

And you radiate warmth. You’re charismatic and you pull people in and you’ve gotten things done. So they look at you, and you humanize it. So they can imagine that they could also do the things that you’ve done.

Well, and certainly they could.

You break that separation

And I’ll just call it out. And you are a role model for an number increasing number of interventionalists who are women who look at you and say, “Wow, I can be president of SIR and I can be on the ACR and I can get all these.” So it’s been hugely important, but I think, you may not realize how you’ve done it or that you do it, but you do.

Oh, well, thank you.

You know what I was to do in a case because we realize that we inspire people very, very differently and people are awake to something at different points either during the day or their career. But I’ll give you a very simple example. In any TIPS case, I’ll pull the medical student in, even if they’re off to the sides and they’re just there for the day. And then I put the device in their hand for the deployment and I say, “I need your help here. I need you to hold your hand like this, brace your elbow at your side. And when I say, I need you to pull this back so we can get this done,” and they release the device and I say, “Don’t watch your hands. That’s what surgeons do. We’ve evolved beyond this. We can watch a screen.” And they watch the screen, they do this, and the device is released. And I say, “Did that feel like thousands of dollars? And in your experience of creating these shunts, how is that ranked?” And it’s amazing to me. People come back and years later and say, “That was a defining thing for me.” But for someone else, it’s going to be an interaction with you, John, when you’ve had a conversation about how to do a study or an animal experiment or a disease that you’re passionate about or what? Tell us.

Oh, I don’t know, Ziv. In theory, everyone you have to work with in a different way and everyone, as you say, is going to be receptive to a different kind of encouragement. I think the most important thing is I always felt encouraged and supported. And that’s by people like Anne, but people like by you. And that’s what I try and do. I just try and let people know you can do this, you can be this. There’s, there’s really not going to be a barrier. You just have to keep working at it.

I think people have gone into this specialty, tell me if you disagree, for different reasons. At the start, it’s the ability to play video games in humans. You turn something and you rack up points on a screen. And that adrenaline thrill that we’ve all talked about that brought us into it. And I still recognize that that’s a lot of it. but at some point, when you say to somebody, “You’re a machine,” and outside of medicine, that sounds like an insult. But in fact it means that you’ve contained the aspects of it so that you can make something complex look mundane so that anybody can do it. And my goal has been to try to approach mastery, even if impossible, which means making very complicated things, look boring to people and to me. And yet you have to have that adrenaline for the trainee to inspire them so that they can then seek to make it boring. And then focus on some of the things that you’ve made very important in your career, Anne, which is how do you make this a clinical specialty? And not just the plumbing.

And that’s, I think, one of the ways that interventional has really evolved because when I started off, we basically took orders from people. We need to have whatever it was; we need to have something done. And we would go and do it. And a lot of times we were doing it because nobody else could do it, which is what John already said is one of the great things about interventional is you know you are the last resort and if you don’t get it done, this patient is going to die, but you get it done. And so I think that things have changed. And I think my personal feeling is a lot of it, I mean, Barry Kasson was incredibly influential in getting people to realize the importance of doing clinical medicine, of seeing patients and they became your patients.

They weren’t just being referred from somebody else. They were actually your patients that were coming to you because you would do something that they needed to have done. And I think particularly with uterine artery embolization, that was a real turning point because the gynecologists really didn’t want us to do this. They didn’t really think it would work. But women started seeing that yes, there was something that could be done other than having to have a hysterectomy. But to do that, you had to see those patients, you had to see them in clinic, you had to do their procedure, you had to follow them in the hospital, you had to follow them in clinic. And then you followed them for six months or so to make sure that everything was going well. And that was a whole different paradigm shift, I think. And that has just expanded so that now if you’re going to treat patients with hepatocellular carcinoma, same thing. You need to see the patients in clinic, you need to talk about tumor boards, what’s the most appropriate treatment, and then you go off and do the treatment.

You got to admit it though, there are few things more satisfying than taking somebody who’s very disabled by an illness and returning her to health.

Oh, absolutely.

To complete health to normalcy.

Yeah, and getting that feeling because you’ve seen that patient over the time period. Before, if we had been doing it when I first started, we would’ve done the embolization. And that would’ve been it. You wouldn’t have necessarily gotten that follow-up.

I have patients that I’ve followed now for more than 22 years Yeah. And their families as well. And to me, this allows me to look back at where I was, which is I wanted to reach numbers of people, and now I can have that clinical care back in my specialty. That internal medicine gene is fed now by modern interventional practice. These are clinicians.

I was just going to say that that is an incredibly important point, what you just mentioned, the longitudinal follow up that you’re talking about in your patient of 20 years. Yeah, I’m in the same boat now, some malformation patients I’ve been following now for over two decades. It’s a completely different relationship to walk into a room, to do a procedure on somebody that you have a real personal relationship with. Everything changes as opposed to the old days, where you’d come in the morning, there’s a list, you go in and you do this thing to somebody that will change their life forever. You’ve never talked to them beforehand, and you’ll never talk to them afterwards. And that is the really big difference over time, is that we now understand that what we do is incredibly important. It influences people, changes their lives forever. And we have the responsibility to follow them, lead them into it, and stay with them afterwards. Even if it doesn’t go well, you have to stay with them.

I think this is a tricky challenge that still has to be solved mechanistically in practices where you hand off procedures through partners, and they come in and take care of a patient that you’ve set up because you can’t provide that care. And those are necessary part of medicine, but they’re steps backwards from where we aspire to be.

Yeah. But everybody has to deal with that. You can’t be an internist to be on call all the time to be ready to available for your patients. Someone has to cover for you. As a surgeon, you take vacations, your patient comes in and someone needs a follow-up operation. So I think this is part of healthcare delivery and that’s actually great that that’s where we’re at because it means we are where we should be as clinicians. We’re not just providing a technical service on demand, but we’re right there shoulder to shoulder with all the other clinicians dealing with the same process, practice problems that they have.

There’s a very mechanical step in the EMR that kind of defines where you are in the evolution of IR, which is, are you in the place where they can order a procedure? Are you in the place where you’ve changed the EMR to say inpatient or outpatient consult? And for what? And then we’ll decide what we’re seeing them for rather than “We’re telling you we need X.”

Yeah. So the the key is we’re not just technical experts, we’re content experts as well. And so we’re being asked for an opinion based on the material, the content, the pathology, and we may or may not have something we can provide to take care of that. And we give that opinion. Very different than what I remember as a resident.

The two of you have done fundamental work in turning this into the specialty that does that by its training, invested in it. We’ve all admitted patients for 20 to 30 years here. We’ve been doing this for a long time. This is not something new, but this is now established, expected, and recognized. Do you want to talk about how many years it took to turn it into this? People think that this was sort of two years and now we’re a specialty. Tell them the truth.

Well, John and I, but particularly John, spent a lot of time getting us to a specialty where we were, in I guess, 10 years.

Oh!

15 maybe?

Yeah that’s just when the crystallization of the idea to get to that point. But everything that led up before that. So Barry, all of Barry Kasson’s work, writing on being clinicians, all the work that was done before, going back to Dotter’s original quote, “If you don’t take care of patients, you’re just a plumber.” I don’t remember the exact quote. This has been, since the beginning, a direction that everyone knew we need to go in. Gary Becker was working on this. Jan Durham was working on this, just an incredible number of people. And it was really probably in mid 2000s that we just committed to say, we’re going to push to get a change in designation. The reason for that was to really build the clinical training into the training program.

But this was a real run against resistance. This was not a “We’re ready, here are our papers,” and walk through the door. Right?

This was change management 101, right? And it started, and you need to identify who you had to convince. And the most difficult group to convince to move from being a subspecialty to a specialty, to change the training, was actually us. We were. That was probably the most challenging group to convince as a whole that we needed to go there. And there are many iterations, and this is why we’ve ended up with a structure that we have, which is an incredibly flexible structure that allows people to do all sorts of different things with their careers. Surprisingly, most of the other organized specialties welcome this. And their response was, yeah, we want you to have more of a role in consulting with these patients and following them afterwards and helping us identify when things need to be done, and doing them, not expecting us to know that. The obvious players that didn’t want it to happen were the obvious players, and there’s no need to go over that. I think most of this was actually welcomed by our clinical peers.

But it was a real struggle. I mean, the scope of trying to change from a subspecialty of diagnostic radiology to its own specialty was a huge process. I mean, we had to go through so many different layers of doing this. And even when we got the designation, that was kind of only the beginning, because then we had to develop the training program and all the requirements for the training program, and then we had to get people signed up to do it and people to go into the match. And it just went on and on and on. It was amazing.

I watched this peripherally. And, by nature, this is the thing that I least like to do. And I’m so happy that I’m no longer a program director after 15 years. So it’s just astonishing me, how much numbers, information, flexibility, as you said, change management. But how did it feel? We all worried medical students won’t discover this. How did it feel to see that when this came out of the gate, this was the single most competitive specialty out of the gate in all of America, in all of medicine?

It was great. I mean, we all felt that that would probably happen.

Really?

Well, yeah. I mean, we think this is the greatest specialty on earth. So of course we thought that this would kind of happen. But the other thing I think is really critical is the SIR, and in terms of, particularly the residents and faculty, but a lot of the residents who really did outreach to medical students to show them what interventional radiology was all about. And that’s how.

We’re back to inspirational. Inspiration and modeling.

Yeah.

And living by example every day. Right?

Right.

Yeah, a big part of this was, as we gained momentum—there were the early adopters who got behind this, we gained momentum—more and more people started getting behind it. So by the time that we were rolling out the residencies, everyone was on board. I think initially everyone is naturally a little skeptical of change. And for the very same thing that you’re intimating, if you don’t really know what the outcome is, it’s hard. And you have something in front of you that’s working, you feel like it’s working, why change? So that was the hard step. But as we gained momentum, people really got behind it. And it was a relief, frankly. It was just a relief that anyone applied. I mean, there was this little fear, like, “We’ve been kind of pushing this for a long time, and what if we build it and nobody comes. That could be a big mistake.”

This is like Mickey Rooney and Judy Garland, “Let’s put on a show.”

Yeah. It could be kind of a colossal mistake, but fortunately I think everyone, as people thought about it, began to realize that this was going to be the way forward. And it’s, I think, played out so far that we are getting great people coming into the training program.

I want to point this in a more personal direction for each of you. Have there been career pivot points where you’ve made conscious decisions that you want to move in a different direction or you’ve changed your own careers, you say, “I now want to focus on this,” or something that in retrospect, even unconscious, led to something different?

I don’t know. I think that for me, what I did was just to, if an opportunity presented itself, I just took it on. And I didn’t know where it was going to lead, but it seemed like it would be a good thing to do at the time. And I think for me, I didn’t ever stop doing clinical work, but I sort of piled on organizational stuff. And I think that that, to me, was a way to give back to the specialty and give other people the opportunity to be involved. So that for me was just what I liked doing. And I think that some people go off on one way or another. I mean, you went off to become the journal editor, an, I know you kept doing clinical work, but you spent a lot of time being the journal editor. And actually talking about things that changed, you’ve got to remember that: how long’s the journal been there? 20 years now?

More than 30.

Oh, more than 30. Oh, okay. I’m too old.

Hurricane Andrew blew the roof off the journal, almost took it down.

That’s right!

You nailed that question in Jeopardy.

But the thing that was interesting about it is that there was a lot of skepticism about starting a journal. And it was a big push to say, “No, no, no, this would be really good.” And Gary Becker was a staunch advocate of this. And so it started, and it was small to begin with, and it was every few months or quarterly or something or other. And then it gradually expanded and it got more and more.

I made a very conscious decision at an early point in my career where somehow I figured out how to write because there were interesting things to write about. And like most of radiology writing at the time, interventional was the same, which is, “We did this. Isn’t this cool?” And whether it’s 1, 10, or 100, it’s still that. Diagnostic radiology was the model for describing these things. The early TIPS ultrasound papers that said 93% sensitivity, by incredibly esteemed authors, were: the patient comes in, the ultrasound looks good, then the TIPS is okay, if it looks abnormal and ultrasound, then we do a venogram. And that’s how we test the sensitivity of ultrasound. You use the test that you’re testing to determine whether or not it’s accurate. And these are papers in radiology. And I said, “We’re not going to go anywhere unless we have prospective studies and we have to have controlled studies.”

And I made a very conscious decision that I wanted to go in that direction and drive that. And each of the large ones I’ve done have been seven years, from start to finish, that have led to things that have had impact. And I think it’s important, and somehow that got me into the journal. That way of thinking which is we have to develop that kind of science that stands on its own, that stands against everyone else’s literature and show that we can do this. And then people in our specialty will come up with us as well. And I think we’re really at that point where there is that expectation that when you read, you expect this kind of work to read just like the New England Journal, within the limits of what we can bring to it.

Sure.

Yeah. Huge sea change, right? Over the last 10 years in our journals. And you were a big part of that, whether or you want to admit it or not. And but that’s part of the maturation of our specialty, of becoming, of growing into our body form, so to speak, of the specialty is to have that kind of great data. And it’s just really exciting to see this and to see the number of NIH trials, multicenter, prospective, randomized trials that are now led by interventional radiologists in areas that are not just interventional radiology topics, but they are affecting all of medicine, right. All the patients.

So we can sort of circle to what we talked about, the adrenaline excitement, the reason that people go in, that individual patient that may turn the light bulb on for somebody. And that cowboy aspect of IR of like, “I’m going to steam it. I’m going to make it, I’m going to invent a new procedure.” And we’re off. But at the same time, we have to support this idea that, like soldiers, where there’s data, we’re going to march in support of the data. Aspirin reduces stroke, you take aspirin, you don’t say, “Yeah, I know, but I think that you don’t need to do that.” We need to evolve, all of us, to say where there’s data, we consume it, we read it, you give it to us the way that we want, and we’re going to act on it. And that’s, I think, the next sort of evolutionary step that we need, that I think is being built into this next generation, I hope.

Yeah. I mean, isn’t it incredible that we’re no longer, “Look what I did, I bent this wire in this way,” and now that’s a publication to here’s a hypothesis-driven, prospective, randomized research to really address important clinical questions that aren’t just solving a technical problem. They’re, they are really dealing with healthcare issues.

Yeah.

Yeah. And I think that that’s in incredibly important because it allows us to be on another level with the people that we’re working with, the other specialties, because now we can come and give and show the data that shows that we know what we’re talking about. We’ve done the testing, these are the outcomes, and that allows us to be on a different playing playing field than, “Oh, well we can do this. And that’s that.”

So have we reached that recognition inflection point, or as you described it, Anne, as the activation energy where we don’t say that that our friends and partners don’t know what we do, our moms don’t know what we do for a living? Have we reached that point, or what’s it going to take?

Well, I’ll ask you the test question. Last time you got in an Uber and they said, “What do you do?” What did you say? And did they know?

When I was in high school, my dad said to me, “Ziv, maybe you should also become a plumber to have a backup profession that things don’t work out for you.” First-generation immigrant, still an intellectual, but he said that to me. And I think he might have been half sincere. And the irony is that here I am as, as a form of plumber.

But the interesting thing is, going back to your question, John, I don’t usually do it with Uber drivers, but oftentimes when I’m on a plane, somebody will say “What do you do? “And before, it was like, “I do interventional radiology,” and they look at me and then they say, “Oh, so so you radiate people with cancer?” And I’d go, “No.”

With charisma, that’s what you should say.

Yeah. But now, “Oh, yeah. Oh, I’ve heard of interventional radiology. I had a friend who had a uterine artery embolization procedure for her fibroids.”

God, that must make you feel great.

It does! I mean, it’s like-

And do you get up when they call for the doctor in the airplane?

I do.

How about you, John?

Oh, yeah.

Yeah.

I do as well just to see what’s in the kit. And it’s amazing. We know what to do in these situations. They’re having a seizure, they’re having potentially an MI, or dyspepsia or whatever. We actually know what to do for these things. We may be the only doctors in a plane full of people who get up.

Yeah. Well, and the other thing is that sometimes other doctors get up, but not necessarily ones that are terribly helpful. It might be, I don’t know, psychiatry or OBGYN or something that gets up trying to be helpful. And sometimes even with people that maybe just sort of do internal medicine they’re kind of like not really sure what to do at the time. If it’s an ER person, that’s great, they know what to do, but not necessarily somebody that does general family practice.

Yeah, Ziv, I think at the system level we are getting recognized, and I don’t know whether it’s a direct outgrowth of being a specialty or just the recognition that image-guided intervention is so critical in healthcare at this point. So there are many system-level IR recognitions that are very different than 20, 30 years ago when we were buried within the diagnostic department somewhere down there.

I think that hospital executives realized that they cannot run a hospital without interventional radiology. And at the same time, we have interventionalists who are who are at the c-suite levels providing support and in those kinds of positions. So it’s happening from both directions.

Yeah, it’s huge to have that recognition. It really is.

Well, and I think it’s so important because I’ve thought about this in terms of the patients that we have in the hospital, honestly if there’s a patient that’s in the hospital for more than maybe three or four days, for sure, we’ve been involved with them on some level because nobody can do that. Nobody’s taking care of the patients. There’s something bad that’s going on and we get involved.

So let’s switch for a second, John. What are you doing when you’re not working and writing and answering emails?

That is the most dreaded question in any kind of a conversation, you know. So nothing really very dramatic. I’ll just say I like to cook. I like to cook a lot. And roast coffee, I live in the northwest.

Can you fix your own espresso machine?

I’m still just with drip. And I have about 20 different kinds of green beans in the house, and I can just rotate roast whatever I want.

Wow, I couldn’t imagine that. That’s magnificent. Anne, do you get your coffee from the Kaufman Roastery? Or have you got your own? What’s your ax for off hours?

I’m kind of like John. I don’t really do a whole lot. I go to bed early, I get up really early. I go to the gym, and I travel. That’s kind of my extracurricular activities, I guess. You, I know, have lots of extracurricular activities

We used to say, “Where in the world is Anne Roberts?” for decades, as well.

I just came back from Morocco.

Yeah, it used to be “What continent is she on?” But now it’s down. Have you counted the number of countries you’ve been in?

I haven’t, I’ll have to do that sometime. I’m more interested in the ones I haven’t been to. So I’m working, I’m trying to skim that down.

I’m sure you’re up to 80 to 90 probably.

Maybe.

Yeah. Ziv, I think we’d all agree as phenomenal a profession that this is, how captivating it is, how consuming it is. In the end, it’s always your family, right? So always keep that perspective.

I talk a lot, like all of you, about how you start a career, how you master the skills that potentially let you decide if you want to be an academic or otherwise. And in all of these types of things, somewhere, I show a slide of a gravestone and it says on it “wrote another paper.” And the answer is, nobody talks about that.

Did 101 TIPS, right?

Yeah, exactly. It’s family, it’s friends, it’s relationships, it’s all those types of things that that fill your life. I got an award this year, and I’ll tell you that the most fundamentally satisfying thing about that a day ago was that my parents were there, my elderly parents, my family was there, my daughters, my wife. And two of my mentors said extraordinary things to me about that. And that has among the things of the love of people in the room and all the congratulations, those are just so fundamentally compelling to me.

And congratulations on that. Very well-earned.

Well, I follow in your steps always. I’m always in your internal combustion effluent and in your easy effluent.

I follow in Anne’s steps.

Yeah. There we go. Anne, it’s circling back to you.

Yeah. Well, I don’t know, do you think that you’ve got some idea as to what your vision would be for the specialty?

Oh, we’re going into the megatrend section. So what’s it going to be?

Oh, let’s take our time on this one.

Okay.

We can take our time a little bit on this one.

Yeah. I think I would look back to look forward. So we are going to be even bigger in terms of our footprint in medicine and our impact on patient care. We will be taking care of diseases in doing procedures that we’re not even thinking about today using technologies that don’t exist today. And we’ll still be the most exciting specialty in medicine. That would be my vision.

Anne?

Hmm, well, I would kind of agree.

You kind of wused out on that, by the way, John. I want to call it out. You said diseases we haven’t taken up, we’re going to come back to you and nail it down.

But I think I agree with John. I think that those of us that have been doing this for a while know. When I started out, the things that we were doing were minimal compared to what we do now in a way. We use the same techniques, and that’s one of the things that I really try and tell the residents. Don’t focus so much on exactly what you’re treating and how you’re treating it. Focus on your technique and how you do something because you’re those techniques you’re going to expand over time in a whole bunch of different directions. I mean when we started out, pretty much we were worried about stopping bleeding, whether it was GI bleeding or somebody that was hemorrhaging from pelvic trauma. That was sort of a lot. I mean, sure we were starting to do angioplasty, so we were doing some angioplasty, but a lot of it was, like I say, stopping bleeding or doing a diagnostic and angiogram for pulmonary emboli, because that was the way–the only way–you had to see if somebody had a pulmonary embolus.

You’re talking about this sort of “the toolbox” aspect of interventional medicine, which is that we’re training people to be able to make analogies from system to system and to be able to face conditions that they haven’t met before. But say this worked elsewhere, I can probably, or I can with contents apply it here. And I remember in fellowship when I talked to Ernie Ring and I said, “I haven’t done that much kidney work in our specialty,” and he said, “You know, the kidney’s like the liver, but easier.” And even in this incredibly succinct and funny thing, he’s right because the techniques carry over and we face things constantly that allow us to create new procedures by analogy, because this is what we’re wiring in skills. And that’s hard to explain to other specialties, but it’s fundamental to IR.

Yeah, and I think the thing about it is, is that when you technically have skills and you understand how you’re using your equipment, then as things change, for example, pulmonary angiography, you would do that because you were trying to diagnose pulmonary emboli. Well now CT diagnoses the pulmonary emboli, which is great because we don’t have to come in in the middle of the night to do that, or do it at five o’clock on the Friday when everybody decided they need to have a pulmonary angiogram. But now we use those same skills to do procedures with embolization or taking out clot in the pulmonary arteries. So it’s a huge change, but it’s the way that this specialty has evolved,

For me, a big change was MSK. Because until then, I had not picked up a hammer and hammered a nail into somebody. And that was somehow fundamental and different. I thought that was a line that took a little while to get across. And yet it’s mundane now.

I’ve been thinking about that question, and I would just say, in our closing minutes, I think one of the things that has changed dramatically is the diversity in the specialty. And I think in a really good way because if we’re going to take care of the population of patients in this country in the most uniform way. If you walk through the halls of SIR it is very different than it was 20, 30 years ago. And it’s incredible just the number of women and underrepresented minorities. So I think that’s a really positive, intentional change over time. And so when you say, what are we going to be like 20, 30 years from now, that’s going to be part of that change.

And maybe that’s the closing word because you used diversity in a very specific, important, and compelling way. We’ve all tried to mentor people that are like us and not like us, specifically all of us here in this booth. And we can see the result of it. But we’re also talking about the diversity of diseases, diversity of approaches, diversity of practitioners, whether they’re in hospital systems or entrepreneurial outpatient labs. They’re going to drive us in very different directions. They’re going to surprise us as well. So a lot of these forces are just the diversity of thought, person, disease that are going to simply make it very, very different than we imagine in years. This is as exciting as it ever was.

Exactly. And that’s the great thing about interventional is it’s always evolving. And there we are, we’re constantly evolving and it’s always been fun.

I want to thank my colleagues, partners, friends, mentors, and inspirations, John Kaufman, Anne Roberts. Thank you very much.

And Ziv Haskal, thank you.

Thank you, Ziv Haskal.