Fellow/residents: radiology roadmap to interventional excellence

Episode Transcript

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics. This is the Cook@ SIR Podcast Series.

Good afternoon everyone. We are live from the SIR—Cook’s podcast booth. It’s a wonderful day in Salt Lake City. And I’m your host, Nishita Kothary. I’m a physician, I’m a professor at Stanford University. And with me, I have two stellar peers, partners, friends. We have Dr. Jessica Stewart from UCLA, she’s an assistant professor. And then we have Dr. Thomas Wong who just graduated from Vanderbilt, finished his fellowship, and is joining a practice in Sarasota, Florida. And for all of you who’ve always wondered how do you communicate and get across people from different generations, this podcast is for you. So I am a Gen Xer, through and through. I still pick up the phone and call people. I actually have very little interest in texting. And then we have Dr. Thomas Wong, who is a millennial and probably knows to text faster than he knows to speak. And Jessica is somewhere in between.

An elder millennial, if you will.

Yes, right. Knows what a phone looks like—a rotary phone looks like—but is not completely clueless about technology the way I am. So welcome both of you. I’m so glad that we are here, and I want to thank Cook for making this opportunity available for all of us as we talk about and navigate our different lifestyles and different ways we grew up in IR. So, Thomas, given that you’re the youngest one and probably the most savvy and cool amongst all of us— although Jessica’s, very cool, I have say. I’m talking for myself, I’m talking for myself. So tell us how’s your journey in IR been so far? What made you come to IR? What were the main key drivers?

For me, it was kind of a personal thing. My dad actually had HCC, and so I learned about IR even before pursuing medicine. And I saw how much of an impact an IR can be for patients. And so when I started medical school, my program— IR physicians were there to teach us radiology and had early exposure, and that’s really what continued to further my interest in IR.

Wow. When something hits you personally, it definitely makes an impact and I’m glad there were IRs who could help your dad. It’s one of the things that we do, and it is what makes this profession very— It touches everybody’s life. There’s a paper that we published where IRs touch 10% of all inpatient population. People don’t realize that, but you are actually making a difference through everyone’s life. And so Jessica, so just for folks to know, Jessica was one of our residents and hopefully we had a positive influence—

I was in med school at Stanford. I didn’t know what IR was going into medical school, but being in Silicon Valley, everybody kind of gets the interest in doing things that are innovative. And I wanted to impact people’s health in a way that I thought made sense with the future of medicine. And I think IR really is that. I thought that minimally invasive procedures are the way forward. And I really liked the innovative spirit of IR and getting to spend time with Nishida and Dan and others in the group at Stanford. It’s hard to not pick IR with that group as your mentors.

Yes, mentorship is. And I think as you guys have medical students and fellows coming through, and just pass past the happiness along, if you will. It’s interesting how much IR has changed though. So I’m going to completely date myself. so I was a med student in 1996. You probably weren’t born Thomas or you were just about born. And at that point IR was an unknown field. And fast forward 20 years, there are medical students coming in saying, “Hey, I want to do IR.” My mom still has no idea what IR is. And my mom’s 90, I give her that, but she’s also a physician. But it is amazing how much we have grown as a specialty in 20 years.

So which brings me to a next interesting question. We clearly have people who are Gen Xers or even baby boomers who dealt with technology where you actually had to hand make things or Jerry Maguire things that was just a part of life. Things were not always available. Nowadays there are things available for just about anything. You can have plugs, you can have coils, whatever you have. I had never deployed a retractable coil. Everything was a pushable. There was no question. Once you put it there, it was there. There was no going back. And so how do you guys look at technology? Thomas, why don’t you start. There’s so much now in terms of technology that I doubt you had to Jerry Maguire anything.

I mean, I think in IR we still do that. I think we still have that mindset that we can make things work even if it’s not perfect. But you’re right, I think even compared when I was a medical student until now, the technology that we’re seeing that was used every so often now in training, we use it every day. Some of these, for example, laser sheaths for IVC filter retrievals, we’re doing it occasionally as a med student, but now it’s just commonplace. But I’d also argue that I think from a patient perspective, like you’re mentioning, they may not know what we do, but they probably don’t even care. They just want to be treated and cared for. And so I think it’s great that we are in this field that is so technologically advanced and evolving, but I think when you’re there seeing the patient, what matters is, like for my dad, actually being there and treating the patient.

And so Jessica, to that point though, you take care of kids, you take care of adults, you’re very patient facing. Can you tell our audience how valuable that is and how much we all enjoy the patient-facing aspect of it?

It really drives everything that we do. It’s spending that time with patients. You’re sometimes interacting with them on the most difficult day of their lives. And it’s important that we remember that and take the time. And that’s one thing I love about our specialty, taking clinic. We usually have a little bit more time than maybe a primary care doctor is expected to see a patient every seven minutes, and we can really take the time to make a positive impact on our patients.

And as a personal anecdote, I would say you’re absolutely right. We have more time in clinic and that’s because most of our patients that we see in clinic eventually become procedures. So you’re not seeing a whole bunch of patients to get five procedures. Everybody is usually treated. And in that case you would be surprised how we become the glue that’s holding the multi-specialty treatment across, especially for cancer care. The number of times where I am the person the patient’s calling for things related with their cirrhosis or things that may not even be related to their HCC for that matter, and that patient contact is actually the most valuable piece and the most— That’s where we all get our warm and fuzzies from. Because as somebody who values us, what we offer. And I’ve had patients call me even after I can’t treat them anymore, when I’m past any other IR option, they still keep in touch with you. And that’s very, very—

Yeah, this longitudinal care. We were talking earlier about vascular malformation clinic. Same with them. You become their physician long term and kind of coordinate every aspect of their care for many years. And it’s extremely rewarding, I find it.

And so for the medical students and residents over there who for some reason believe that IR is not as patient-facing as other specialties, here a three physicians telling you the exact opposite. And I can guarantee if you were to poll whole bunch of other IRs, they would tell you the same: that this is a patient-facing specialty. All right, so changing gears a little bit, like I said, things have changed. Thomas, if you had one thing that you would wish your baby boomers, Gen Xer attendings, mentors could figure out, what would that be?

Oh man, you’re calling me out because you’re saying I’m from that texting generation, and it would be nice sometimes to just text me if it’s one quick thing, just shoot me a text and I’ll take care of it.

Don’t call.

Yeah, I’m in the middle of something and then I feel bad not answering your phone call, but probably that.

We feel attacked.

And so Jessica, you are literally the bridge between these two generations, and you can sort of see it from both sides.

Exactly.

So do you have any pearls of—

I was raised up by you guys, and then I’m mentoring these guys.

So pearls of wisdom for both generations.

Yeah, exactly. I’m just trying to keep up with the lingo on you guys’ side on the young ends. But no, I appreciate texting too and I actually love that our trainees, we communicate mostly that way on call I would say. So that’s very convenient to me. And I think— I love that this generation, this younger generation, younger than me is really embracing technology, and we’re only going to embrace it more and make our lives more efficient. Our practices more efficient and make it a more pleasant way to practice medicine.

And so for those Gen Xers like me who are out there, or even the baby boomers, a note to self: stop picking up the phone and calling every time. It’s okay to text. But the other thing that I think people miss out on is this perception that the younger generation is not working as hard as we are. And I think that perception is completely wrong because I think this is a generation that works smarter. Everything does not have to be answered by just long hours. These are the guys who said, “Well, let me figure out something that I can work smarter, work faster, and actually have a life.”

And I think we should give them due credit for that because the number of folks who’ve missed out on their kid’s graduation, kids getting older, is tremendous in the older generation. That’s a huge number of folks, you know, my peers and my mentors who missed out on that. And so kudos to you guys for actually having a life because that’s what we here on earth for, to have a life and to actually work hard, play hard. Let me ask you this, how is it that you guys have figured out— give me a couple of examples of a work smarter, not longer.

I think just using technology like— exactly what you’re saying is there are things that you can set into motion, let it work in the background and that you don’t need to hover. And trust other people to do what they need to do and then move on to the next task. And I think using technology to your advantage is definitely the way to have more time for family, have more time for friends. And also being intentional, when you set aside time to be with family, be with family. They make a big sacrifice for us being in medicine and we should acknowledge that too.

Yeah, that’s true. And you’re right, trust and teamwork. It’s not individual, it’s just trust in your team.

Absolutely. I agree. I think you’re 100% right about being present with whatever we’re doing. We want to try to be present for our families when we’re at home and present for our patients and our colleagues during work. And sometimes we have to mix the two a little bit. But I think you can try to set some gentle boundaries. I think Nishita and I discussed a few weeks ago that boundaries are difficult to set sometimes. Sometimes what gives me more quality of life is actually blurring those boundaries where I could go home and walk my dog and then come back to some work later tonight and that’s okay. I don’t have to say I have to be done before I go home and deal with anything personal.

All right. And I think to Thomas’s point, being intentional about what you’re doing, being there, being present, but at the same time, some of my academic days. I am attending a PTA meeting because I work early in the morning and catch up on my academic work on Saturday mornings when everybody’s asleep. So some of it is just not being so siloed and so stuck in “This is my nine to five,” but knowing where to give. But that requires intentionality, as you said, and also requires being disciplined. You can’t do too much of either one of them, you need a balance. You need to strike a balance. So I’m going to go back to IR again because here we are at SIR. Jessica, have you noticed a change in the specialty from the time you were a med student to now you being a professor?

Absolutely. And it’s been very positive, I would say. The focus on clinical medicine and really caring for the patient with a clinical aspect in mind. Not being just someone where you order a procedure and you perform a procedure. We’re involved with consulting on the patient and are an integral part of their care team. And I think that’s been a huge shift for our trainees. And with the new residency program matching into IR, we’re getting med students involved who are more interested in being interventional radiology physicians and not radiologists who simply do procedures when asked. And I think that’s been a really positive change for our specialty.

And so Thomas, maybe you can speak a little bit more to how the training aspect has changed completely for our listeners. Because there was no ESIR when I trained. There was actually no match when I trained, believe it or not. So I’m really dating myself. I didn’t have to actually go through five places and interview and do a match. I just— I matched for radiology, but fellowship wasn’t a match at that point.

It was like an email or…?

It was actually a phone call. So Thomas, tell us how has this changed? Which pathway did you go through? And if you could just describe the pathways for listeners for those who don’t know how things have evolved.

I think I’m probably the first big match class for the integrated pathway. I think when I was going through it, the class above me may have had a handful of spots across the country, but my year was the first big year. But it was a lot of unknown. When I was a medical student, you don’t know how many programs to apply to, what to look for. And so most everyone applied everywhere. But I think now having gone through it, you realize it’s such a longitudinal relationship in the program.

You’re there in the department every year for the five, six years. You really develop relationships with not only the attendings and the mentors but also with your co-residents. And you learn so much from each other, and by the time you’re a senior you feel so much stronger and you’re having fun. It really becomes a second family. And so I’m very happy to have gone through this training. Kind of like what Dr. Stewart saying, it’s so focused on being a clinician, being a doctor to somebody, not just proceduralists. And we are technically proficient at what we do, but really being there for patients and being there for each other.

So what top pearls or what top advice would you give to students and residents who are looking into this match process? What should they be looking for when they go interview?

I think absolutely the most important thing is finding the people that you vibe with. It’s wherever you go, it’s going to be five, six years of your life that you’re not going to have back. And you want to be with people that you can call your second family and that you don’t mind going to work every day. You’re in the trenches, you’re on call together, you’re in long procedures, you go through happiness and tragedy. People get married, they have children, people pass away. These are really important life moments, and I’m very happy that I have program that I do that I can share that with.

Can I have a question? Thomas, any tips for students who are interviewing and looking for that kind of a match with a program that is really people that you can call your family in light of all these interviews being virtual now, any tips for them? I mean this has been a very big change.

It’s such a challenge. I am glad I am not going through it now. I mean seeing some of their applications and how strong they are, it’s really impressive too. But I think when you’re talking to the residents and just trying to get a feel for the culture, and I think what that culture means is trying to find people that you identify with, have similar interests, that you want to spend time outside of work together. And I think it’s so important to try to piece that out of what’s the IR program that you want to go and learn and be a good IR, but also the people that you want to spend that time with outside of work.

And Jessica brings up a really important point. A lot of these interviews are now happening over Zoom. That in-person contact may be limited, and you may not see how the person functions in a group of people. And so one of the things is to— I would encourage everybody who’s looking at this if they’re at a meeting or if there’s a particular program that they’re really interested in, pick up the phone—I’m sorry, I’m just kidding—try and meet people who are at these programs, either the fellowship director or even the section chief or frankly just anybody who’s even part of that program. Seek them out. We love listening and hearing from everybody. We really do because that gives us a good understanding of where you are coming from. Away rotations I think are still really important. I don’t know how you guys think about it.

Absolutely.

Probably more so now I think in light of the virtual interviews.

Yeah, and it’s good to see the city that you’ll spend your training in and see if you fit with that city.

I will tell you, my residents and fellows spend a fair amount of time just hanging out with each other because again, this is your family for the next four or five or six years. And they pretty much will go out and have dinner every other weekend or so. So think about who you’re working with, think about where you want to live. Life will happen along the way.

So again, if your parents are in one part of the country, think about that also because this is a generation that is now— it seems to be taking longer and longer and longer to actually get out and do work. I don’t know what it is, but it seems that everybody is actually having kids or parents are older. So keep those things in mind because life will happen to you while you are getting trained. All right, I want to switch gears a little bit and go back to IR in the future. So let’s fast forward 10, 15 years. What’s your vision of what the specialty’s going to be 15 years from now? And then what do you think we need to do today to make sure that that vision of yours is true in 15 years? Jessica?

Yeah, I mean I think the revolution towards clinical medicine will only continue. I think we’re going to continue to establish ourselves as physicians who manage diseases, not physicians who only do procedures. And I think part of that evolution might be IR is becoming more and more independent. I think us establishing our own practices, possibly collaborating with other clinicians who are like-minded might be part of that revolution. Or just going into business for ourselves in a lot of cases where— multiple of our IR colleagues are doing this now successfully. I think that’s going to be part of the evolution of this. But kind of thinking of ourselves as clinicians first and foremost, and as leaders who manage disease states.

What about you Thomas? What’s your vision?

Honestly exactly the same. I think we have to be a patient’s doctor, not just the proceduralist. And earlier we were talking about how the training program, how it’s been different. And I think I’m very fortunate in that one of my mentors, Filip Banovac, he was mentioning when we were picking a program, “How is your training going to be different than 10, 15 years ago? How is your IR training different?” For me, we get exposed to different clinical specialties, how they manage diseases. And so when we’re talking to patients, we know what we can offer them, but also what else is available. And knowing how to counsel them through those obstacles and those challenges I think is so important that we’re actually treating the pathology and treating the patient, not just offering a procedure.

And I completely agree. I think all specialties, including IR, every specialty is going in a more collaborative manner. And again, just talking about 20 years ago, it was very siloed. It was all about turf wars. And if you look at some of us IRs like a decade ago, the biggest fear was what happens to our turf? And the good thing now is that we all realize the turf doesn’t belong to anybody. It belongs to the patient. I mean, they decide where they want to go.

And I think the younger surgeons, the younger physicians, internists and all, are realizing that this is a team sport no matter what because everything’s gotten so specialized that you would have to be a genius to be able to do every one of those bits. And so I think IR is going the same way. You look at the HCC IO tumor boards, there’s not one specialty. There are about six specialties and they’re all determining things. So that is exciting and I’m glad we are part of that. I do believe that we do need solid research behind us and outcomes data. So thoughts on that? Either when viewed in terms of where should we go with a research mission?

Yes. I think those collaborations can play a big role in that trying to generate high-quality data that is compelling to other specialties and to patients that we can really provide effective therapies, but the data has to be there to really drive these referral patterns and patients seeking us out.

Cost was going to be a critical part of it. So talking about cost though, so here’s the flip side of the coin. There was a time when you could just about have any device you wanted, you could do what you wanted to. There was nobody in the C-suite telling you, “Well, this is too expensive or the insurance is not going to pay for it.” We were unique enough that insurance didn’t care about us. I mean, we were just such a small—

We were small fish,

—a small fish that nobody bothered. Now you see more and more the insurance is getting on board. There are denials that our colleagues are dealing with. Thomas, you’re going to be in the heat of this. Like I said, I have another 10, 15 years to go, so hopefully I’m not going to be dealing with too many denials. But you have your entire career where insurance carriers are getting very savvy about what IR does. Thoughts on that, do you think that’s going to be a big determinant of how you practice?

I think having that collaborative research is what’s going to be the ammunition for that, is working with specialists for a certain pathology or whatnot and then working together to identify what’s best for the patient. Having the data to actually support that, and then bringing that to the insurance companies and say, “These are the options. This is why I’m recommending this treatment,” or something like that. And I think that’s where we’re going to have a voice. So I think it’s so important that as a field we continue to collaborate and have that data to help base our decisions.

I think it’s going to be more and more scrutinized. And so yeah, we needed the data to support using our fancy devices and have good reasoning for that.

And do you think big data—or having large data, I know Big Data is a fancy word—but having large data sets, and being able to pool data from all institutions or all practices, thoughts on that? I mean, where do you guys see that happening?

I think the more that we can pool it, whether it’s through registries, through trial networks, anything like that where we could harness some of these abilities of deep learning, big data, to kind of tease out some of these trends and some of these outcomes, we need to use every resource we have, including all this new tech I think.

And having other experts in the field too that maybe aren’t even physicians but aren’t just experts in engineering and AI and things. Having them be part of the conversation. Because certainly it’s not floppy disk, but I don’t know what else it’s going to be, so it’s not my cup of tea.

You know these were actually floppy at one point, right?

Yeah.

Maybe you remember it a little bit.

You’re talking about AI. Do you guys worry about AI? I mean, there’s a lot of chatter in the world about how AI’s going to take over this and AI’s going to take over that. And the good thing is we work with our hands, but then there’s robotics. And Jessica, well, you’re as an expert in robotics, and we are not at a point where a robot can do what we can do, but does it bother or worry any of the younger generation of what AI is going to do to their work?

With respect to robotics, I hope it goes as far as it possibly can because there’s still places in the United States and around the world that don’t have access to interventional radiology care. And I think if we could bring robotics in, affordable robotics, to take care of some of those gaps, I think that would be incredible. And also reduce workload and strain on us, reduce back pain, reduce our radiation exposure. So I hope robotics goes as far as it possibly can. And then as far as AI in general, no, I just want it to help us out as much as we possibly can and be the best doctors we can be, whether it’s identifying a bleed on the angio or making our workflow more efficient with dictations and utilizing AI to help us do things more efficiently in our everyday workflow. So bring it on with the AI. I think it’s great.

I would just be happy if it can write my note for me. That would be the best thing ever. Sorry.

Or we get to have one million tabs and it hides everything in certain contexts. I mean just that would be great.

Thomas, what about you? Any thoughts on how— AI? Yay, nay?

No, 100% agree. I think we should use all the tools to our advantage and be the best doctor that we can be. I think there’s medical students that always ask that question and they’re worried about it. And that’s been something that’s been said even when I was a third-year medical student. It’s been six years now, and it’s still not quite there. And we certainly— I think it has room to grow and room to help us be better physicians. I don’t think it’s anywhere going to be replacing us.

I mean, at UCLA, we’re looking at AI to try and help our diagnostic radiology colleagues where they might have a list that’s a mile long and they don’t know that there’s a tension pneumo buried at the bottom and AI could flag it for them. And this is helping us do better by our patients. So diagnostic IR, I think AI is going to be revolutionary in just helping us do better in the light of increasing demands, which always seems to be the case for us.

AI being able to flag things that need attention would be a big, big help. Or if somebody’s too sleepy and making a misdiagnosis, right, saying, “Hey, by the way, you may want to look at the right corner of this film.”

We’re humans.

I’m trying to figure out how best to— Medical students, because they are some of our listeners right now, are also trying to figure out how to help in research. And yes, some of the work is in outcomes research, some of it’s in AI. So for medical students who are looking into IR, what kind of advice would you give them about number one, trying to find a research mentor and secondly, trying to find that sweet spot of research that they like because it shouldn’t be just another chore.

Yeah. For me, I think it’s great to start with your local institution. If there are people there doing projects that interest you, I think that’s fantastic. But I think nowadays everything is global and interconnected. So people have found research mentors using social media, they’ve found them at conferences, and there’s nothing that says that you have to work with somebody at your institution if you’re not finding what interests you and what excites you there. And it can still be a very meaningful experience working remotely with someone on research projects. And also there’s summer opportunities and things like that where you can explore. So even if you’re at a program where you don’t feel like you’re finding the kind of research mentorship or the kind of projects that you’re interested in, you can still make it happen for yourself and really find a project that you personally find rewarding.

And as Jessica mentioned, there’s the SIR summer internship. So for those of you looking for research opportunities, investigate, look into that because that’s a great place to do research virtually. Thomas, before you went to Vandy, how did you decide on Vanderbilt and did you work with Dan Brown beforehand or?

No. Yeah, so after you were saying don’t let geography be a boundary. So one of my early mentors in IR, Jason Hoffman, he was in New York and I did medical school in Colorado. But I had met him through other mentors in Colorado and met him at conferences, and we collaborated and he guided me through some research projects that I found personally interesting. And it didn’t matter at all that we weren’t in the same state. You know, an email’s an email, text message is a text, phone call is a phone call. And he really helped, guided me into the field of IR when we were together. And we are still in touch now. He still helps me with IR clinical things and also just personal things. And so it’s been a great relationship to have that available.

I agree, Thomas. The research mentor-mentee relationship is really a long-term mentorship relationship far beyond when the project is finished. And that’s somebody that can continue to advocate for you and work with you wherever you both are in your careers moving forward.

Yeah. And these are mentors who can also help navigate life because, believe me, we’ve been there, done that. The same stuff happens to all of us, maybe to a slightly different degrees, if you will. I think more people are dual working couples now or with kids. And it has changed a little bit. There was a time when I did a survey where most of the men had stay-at-home wives. That’s changed. That has very much changed. I mean, most of my fellows and residents and med students have a dual working— and I’m a dual working— and my husband works and I work. And so let’s talk a little bit about “work-life balance.” And I know we said that it’s a little blurry, but just making things happen. Jessica, how do you find time in a very— I mean, UCLA is a busy practice. Do you have days that you are academic and off work and just get about doing your doctor’s appointments and stuff like that?

Yeah. Luckily we are in a practice that’s big enough where we do have some academic, time and we are able to take care of ourselves during part of that time. And I think that’s really important to have a little bit of flexibility in your schedule if you can. But otherwise, you might have to just schedule it for yourself instead of planning for a vacation, maybe take an off day of your vacation day and just get those kind of things done so that you don’t completely burn out. And make sure you’re taking care of yourself over time. But obviously it’s different for every practice.

And so Thomas, you’re going to go into private practice. How do you plan to—and I know you’re just starting off—but how do you plan to get some sort of semblance of getting life done at the same time as work’s happening?

One of the reasons why I chose the group that I’m going to is, I think there’s that culture there that people are there to support one another, that they understand life, things happen. And when I was having dinner with them, chatting about just how work is, how call is, and these are people that are saying, “Oh yeah, when there’s a tough case, I’ll come in and I’ll help out.” And they were telling me about overnight TIPS or something, and another person just came in just to support. Or on the flip side of that, one of them was having some sporting event with their child and then they invite their colleagues and like, “Hey, you want to come over and watch my kid play soccer?” And I think just that work-life balance extends to your partners, and that was the type of culture that I wanted to be a part of.

Absolutely. That’s so crucial to have that level of support because unexpected things come up. They do. And you have to have a good team who all has each other’s backs with respect to those kind of things. I know you guys do at Stanford for sure.

So what I’m hearing from both of you guys, and I 100% agree, is it matters who you work with. It really does. And so when you’re looking for a job, really make sure that you like the people who are there and that they actually have a good team approach. Because the 10,000 extra dollars that you’ll get in practice B, which is not as supportive, will not be worth it when you actually have something happen that you need time off from. So I think that that culture is really, really critical and that hasn’t changed. And one of the things we were going to sort of talk about is that there’s just more similarities than differences as we go across the generations.

And I think the biggest similarity is this: your work family is your family, but it’s a family you can choose as opposed to the family you cannot choose. So given that you have the ability to choose this family, make your choices well. I do want to touch a little bit on industry collaborations because one of the other themes is that we talked about is collaboration, right? Whether it’s across medical sciences, across physicians, but I think there’s a lot of collaboration with industry also. It has evolved. You no longer can make things in your garage, but how are you approaching, Jessica, how are you approaching industry? I know you work a lot with industry.

Yes, yes. Research is a big focus of mine. Research funding is getting harder and harder to come by, and our industry partners have the same interest as we do much of the time. They want to get good data that supports the use of their devices. We want to get good data that supports a procedure to treat a patient in the most effective way. And so I think there’s room for collaboration there with respect to research funding that is becoming harder and harder to come by from some of the national, like the NIH and from the foundations. Times are tough with respect to research funding. So I think that is certainly a win-win relationship with respect to research. And also they’re interested in education as well, and they can provide some great resources, especially for our trainees as they’re learning more about their devices.

Thomas, what about do you hope to work with industry? In what context would you love to work with industry? Again, I know you’re just starting off, but I’m sure you have dreams.

Yeah, well, I think industry is great because I think it’s an underutilized or underappreciated asset and education. I feel like I’ve learned so much even from Cook, I’ve had the pleasure of going to a couple of the Vista courses. Those are great to really learn about some of the devices and some of the procedures in a very controlled environment. But I think the other thing that’s great and also different than what I learned from my mentors at work or at my residency is sometimes why is it designed or why is the product designed the way it is? And having that process, I think it is very interesting and I think it makes me more appreciative of how to use a certain device knowing why it’s designed a certain way. And I think I want to continue that relationship moving forward and being on the cutting edge and helping with education too.

So you mean the engineering aspect of it, right?

Yeah.

Which was very cool. And thank God for companies like Cook that put up these educational things because again, this was one of the few things that wasn’t available early on. There were no companies putting up educational courses and definitely not the engineering backbone to it. The education was how do you do the procedure? It wasn’t so much as to here’s why the design is X, Y, and Z. So that is unbelievable. You’re right, that has changed.

And I mean if we don’t engage with the companies, then they don’t know what we actually need in our clinical practices. So it serves us to participate in that process, I think, in the design process and letting them know what the problems are that we’ve run into, what the needs are. So we have better ability to treat our patients when we interact with industry, I think.

So there are med students, residents, even junior attendings, the people from all sorts who are a little bit worried about conflict of interest. COI is something that’s, people want to make sure that they’re not in any a way or shape damaging the patient-physician relationship. Conflicts— hospitals have lots of COI rules now. And so can you guys talk a little bit about how you approach this? What’s your thought on conflict of interest, Jessica?

I try to obviously maintain impartiality as much as I possibly can. I try to work with multiple companies so that I’m not really favoring one too much and try to view it from an objective view. But obviously all of this is going to get reported. It’s visible to your patients and it’s something we have to keep in mind. But also it is an effective tool as we’ve already discussed. So it’s a tough balance for sure.

Thomas, thoughts on COI?

I think having data is very helpful to know why you use a certain device or why use some different tech and having that to help you decide what to use it in a daily practice I think is very important. And we’ve talked about how industry really supports that in terms of research and getting data. So I think it’s important to continue to work with industry, but also to be impartial and understand that you want to have numbers to support what we’re doing.

And I like Jessica’s point a lot in terms of when you work with multiple companies, by default you are essentially being neutral because now you are sort of giving the same thought process to four different companies in the same space. One thing of course to be careful about is disclosure. Everybody who works with a company will have to sign a confidentiality agreement, which means you can’t take the IP from one company and talk about it to another company. But if you’re careful, which most of us are, then you really are helping just that entire disease state get better technology for the disease state because now you have multiple people working in that same area. So I would say don’t worry about conflict of interest. The one thing to keep in mind is your patient should always be the North star, and if you keep your patient as a North star, you will be fine with the COI part of it because as long as you can go to sleep every night saying you are improving the specialty, you’re not doing it just for the reimbursement or for the consulting fees, you should be fine.

So again, there’s lots to think about in COI, but don’t let it overwhelm you. The one thing as Jessica and Thomas mentioned is that it has to be disclosed. And so anytime you’re doing a lecture, make sure you disclose that these are the companies you’re working with. And at this point, I believe even patients are, so for example, at Stanford, our patients get to see what our conflicts are, but most patients just want you to help them for the disease state. They really don’t care whether you work with company X or company Y. Any other thoughts on conflicts and working with companies? I will say that companies really do want our— would you guys agree that they want our input? That’s what makes them better. So as an aside, Thomas, did you ever approach anybody when you were a med student or a resident, did you go speak to— How did you get involved with Cook? Because I said you’re relatively early in the specialty. So did you just approach them and said, “Hey, I have the cool idea,” or did they approach you?

No, I met Cook at a guest at one of the conferences, and we were just chatting about some of the equipment. I ended up winning one of the trivia night things. And so it just was a good way to open a conversation. And so it’s talking to them. And then again, I was really interested in learning about some of the technology and why it’s designed that way and Cook just had the patience to have some of the clinical reps actually go through that this is why we designed this way. And I think that was just very interesting and just kept that conversation going.

Jessica, did you approach them when you were a trainee or was it post-trainee?

It was all post-trainee, and I think it was a combination of having a common interest in certain disease states and certain devices, I think. And then I think to some extent also a personality match between you and the company can really work out and whether they share your vision and excitement for what you’re working on.

Yeah, that is neat. I’m trying to think when, I can’t remember, I’m assuming mine was post-training because I can’t remember—besides just working long hours, but there was no 80-hour week at that point. I don’t remember ever approaching a company, but you’re right. At a meeting like SIR, all the major companies are here, and they are really looking at the younger generation as the next forefront. This is the next frontier. These are the next people who are going to be taking the specialty to a higher level. And so I think if you can approach companies, look at their devices, they will always be willing to talk to you about it.

And that’s a good way to get an introduction to the industry because IR, unlike a lot of other specialties, is very intertwined with industry. It’s the rising tide. When we do well, industry does well; when industry does well, we do well. And our patients are the winners in all of that. So I think we are at time, I want to have some final thoughts from you guys in terms of what we said initially is that we are more alike than different across the generations. And so with that in mind, do either one of you have a real funny anecdote about dealing with, like I said, a Gen Xer like me or a millennial dealing with a non-millennial? We have three generations over here.

Well, this was not happening to me, but I mean, just a difference between practice now and then. I used to hear stories about someone who would lace a clot with TPA and go out and smoke a cigarette. So I don’t see a lot of that anymore.

True that.

But I mean, yeah, things are different these days, but overall, we still have the same goals and we all love IR, so we really do share that.

I’m into that. What about you, Thomas?

Man, I don’t know.

I promise I will not tell Dan Brown about it or Filip Banovac about it. I mean, you can make fun of them. You have their permission.

I’ll say it is always okay to call. Sometimes it is very helpful to have a phone conversation. But likewise, I never really feel like there’s a generational gap in IR because I feel like we’re also heavily invested in just doing what’s right for our patients. And I’m in the integrated residency, but my teachers are positions in your generation and they’re equally invested in that. And so I don’t feel like there’s really a generational gap. I think we’re all growing together and learning how to train the best positions in IR.

That is so true. That is so true. I think the single goal is to make IR even better than it is today, which I find it hard to imagine because I already think it’s so awesome, but I am so looking forward to the next 10, 15 years of how this— We’ve seen so much change already, this is only getting better. So with that, thank you so much again. I want to thank Cook for giving us this opportunity to just shoot the breeze and have a conversation. And then Jessica, thank you so much for being here, Thomas, so much for being over here. It has been my absolute pleasure talking to both of you.

You too.

Bye-bye now.

Thanks a lot.

Thank you.