Innovation changes with products and procedures

Episode Transcript

Good morning everybody. We are live at SIR 2023 from the Cook booth, and I have two fantastic people with me talking about innovation and what it means in this day and age. We have Dr. Kavi Krishnasamy from Columbia. He is an associate professor, is the director of research, and co-director of the IO Service. And then of course, Dr. Lindsay Machan from University of British Columbia, who’s also an associate professor. And we all know Lindsay as the innovator that he’s always been. So, welcome everybody. I’m Nishita Kothary, I’m a professor at Stanford University, and I am excited to talk about innovation. So, yeah, welcome everybody, and welcome Kavi, welcome Lindsay. We are going to first start off with a very basic question, but that has so much depth to it. What does innovation mean to you? And more importantly, what innovation have you seen through your lifetime? Because we all come from three different generations of IR. So Kavi, you first.

Yeah, sure. So it’s a big topic, right? Because in it, there’s innovation in everything that we do in IR, it’s the bread and butter of what our specialty is built on. I went to the Synergy dinner last night and we saw the classic Charles Dotter video with the explosions and the Dottering and all of that, right? And you know, so one way to frame this, I mean, I think for me, having trained in a traditional pathway, you know, one of the biggest innovative changes that I’ve seen in the last few years is the training pathway change, right? And how we are–we’ve evolved and innovated our, you know, our traditional diagnostic radiology pathway to now a true IR residency. And we’re training people in this mentality of a clinical service, which we didn’t used to have.

Even when I was a resident, we weren’t really a clinical service, you know, 12 years ago or whatever. And then now we’re evolving beyond that, how do we train people outside of the lab, right, to be safer in the lab? Because, I mean, let’s be honest, one year, a year and a half, in IR is probably still not enough. I mean, it’s such an overarching, you know, specialty that–and there’s hundreds of procedures to learn, multiple service lines. How do you teach everything? And the classic notion that that your first couple years out of fellowship is still another fellowship, and you’re still learning and evolving as a junior attending. So, you know, we’re working to find flow models and, you know, how can I teach you know, a liver bleed embolization without having to do it in a patient? You know, things like that. You know, simulators are available now. And so it’s a complex question just on the training side, and then that doesn’t address devices, procedures, you know, what the future holds, all of that.

Yep. And so I–you’re completely right on that, right? I’ve been out in practice for 20 years, and even in those 20 years, what innovation may mean to you is different from me. And I guarantee when we ask Lindsay the same question, it will be a different option. And just in this–when you think about 20 years, that’s not a very long time, and yet I think about it and–retrievable filters, we were first–I have put in Greenfield filters, which most of my fellows don’t even know about, right? And I’ve–the Cook retrievable filter came around right when I was doing my fellowship. TIPS? I put wall stents in for TIPS, right? Again, 20 years, that’s not a long time. And now the thought of doing a TIPS with a wall stent is almost unheard of. So, Lindsay, you come from even a generation before that, where you guys were making your own devices and Jerry-rigging things because some of these things weren’t available. So what’s your perspective on what–what does innovation look like and what have you seen happen in the last years?

Yeah. Well, I think the–you know, the basic tentative innovation hasn’t changed, right? From, you know, my first exposure, I was blessed to be able to work with Dr. Stan Cope early on in my career and that was an incredibly lucky thing to watch how a true genius at innovation worked. And I think it’s still the same thing, and it’s just what Kavi mentioned, it’s about solving a problem that’s important. And that’s really at the basis of all innovation. The–you know, some of the procedures where we did make our own thing, when we started off with stent grafts, for instance, you know, we were taking Gianturco Z-stents, which were a revelation at the time, and then sewing our own Gore-Tex onto the outside, and then taking an esophageal stent introducer and putting it up into the thoracic aorta and pushing this thing out with a modified pusher that we created ourselves.

Obviously you couldn’t do that today without sort of looking at jail time shortly after. But it was solving an important problem at the time, you know? And now I think innovation, when we talk about products, we have to think a little bit differently, but we still have to be thinking, are we solving an important problem, something that matters. Now, it has to be a protectable and producible and saleable product that solves a really important problem. And so that is quite different, and it has lots of implications about how long it takes to get into practice. But at the end of the day, it is just that, solving a problem.

But I’ll push back a little bit on that in the jail time part of it, right?

Mm-hmm.

Because at the end of the day, any innovation has to be based out of need.

Mm-hmm.

And we still have so many needs in IR, right? As with–and that’s the beauty of IR. It’s not, well, we’ve only done–you know, this is how it’s done surgically, and this is how we are going to do it, and so be it for the next 200 years, right? All of us work in situations and we go like, wow, it would be nice if this was a little bit better, a little easier, a little smoother. And I think for this generation that’s coming up, there still are a host of problems that need answers.

Mm-hmm.

And so I would say that it still is a very needs-based world, and I think that’s where industry also supports us. Like, you know, what are the important questions?

And that’s just the developed nations, right? What about the developing nations around the world, right? And places where they’re reusing diagnostic catheters because they can’t get enough catheters or reusing drainage catheters and–you know, it’s–that dichotomy is intense on one side. At the same time, it’s a totally different ballgame for, you know, Road to IR in Tanzania, or RAD-AID Guyana, you know, things like that, right? So, yeah.

And again, making it a more global, universally available procedure, technology, whatever it be. I do think where it is going to change for the younger generation is it has to be based on good outcomes. There has to be value, value of IR, value for procedure, value for modality, because as we know, we spend a fair amount of our GDP on healthcare, and it can be the most expensive drug, device, medicine, whatever, without proven demonstrable benefit, right? So I think it’s exciting what we have to offer, but I’m even more excited that we now will have true outcomes-based data before we adopt a new device or a new modality.

Yeah, that’s a great point. Dr. Machan, you want to go on to the next question?

Sure. So, you know, I guess an important one is how do we as staff physicians, train and mentor future generations as it relates to embracing innovation? And how do we have them understand that there are cost considerations for this innovation–any innovative technology? And Nishita, I think why don’t you expand on the point you just made. I think that’s really critical.

It is. One of the first things I show my fellow is a slide that has–it shows how much of GDP that we spend on healthcare. So if you look at the US GDP, 18% of it goes in healthcare, and that’s a large percentage for a developed country, which also needs defense and resources, right? So when people think that we spend a ton of money on our armed forces and defense, it’s actually a very small fraction compared to healthcare. And so what we need to show is that whatever we are doing, whatever we’re developing, has impact. And so I’ll give a couple of examples. Like the Bentson wire, which is probably–I don’t know how expensive it is–one of your basic core wires–I pretty much can try and do anything with that, right? I love it. It’s one of my favorite wires. Coils for example–it’s interesting that I trained in the generation where only pushable coils were available.

We did not have detachable coils. Until today. It is unusual for me to use a detachable coil. I may use it maybe once a year. The younger–my younger partners who all trained with detachable coils will only use that, right? And it just–sometimes I go like, “Hmm, it can’t be–” We are both going into the same artery, it can’t be that different. But I think it’s part of the training where I think we need to let our trainees understand or least show that things can be done in a cheaper fashion, without blowing out the bank.

I think that’s essential to, you know, to actually put that through. And, you know, I absolutely agree with you. I do pushable coils and my younger colleagues, you know, they view it with horror whenever you talk about doing it. And other things, like, just if you’re doing abdominal–if you’re doing any kind of abdominal cannulation, having the patient breathe in or out, something simple, they would never think of that. They’d get out a microcatheter and–don’t go to a basic microcatheter. You’ve got to go to a high end microcatheter. And so, you know, something that costs you–“Can you hold your breath, please, sir?” versus, you know, let’s open that, you know, $600 worth of catheter and guidewire to achieve the same thing. It’s, these are things that have to get transmitted because they need to understand that the more money you spend, the less you can do.

Right.

In the long run.

Yeah. And so, one thing that I do want to add to that, Lindsay, is that, you know, I don’t blame the trainees for using the most expensive stuff, because one of the things that we don’t do in any of our practices, right?–across the board–is actually teach our trainees what things cost, right? So they’re going to Whole Foods, for example, and they’re–imagine you walked into Whole Foods and there was not a single price tag on any one of the things. You’d go for the best cheese or the best wine, right? Why not? Because there is no price tag attached to it. So I think one of the things, going to you Kavi, since you clearly love training and education, is how do we get our trainees to actually understand what things cost?

Yeah. Yeah. That’s a great question. And I’m actually–I’m laughing because I’m very guilty of some of these things that we’re talking about you know, having trained more recently. And it’s a challenge all the way around, because on one hand, as part of the training program, I do feel the need to teach the trainees the breadth of devices, trying new devices, trying different devices, everything from pushable coils to detachable coils. On the other hand, you know, outcomes are also very important here. And for some of these things we don’t have outcomes. How do you transmit the cost part is always a challenge, right? Can we–is it as simple as the MUSC team, right? They put stickers on their devices. If it’s a red sticker, it’s super expensive. If it’s a green sticker, it’s very cheap.

And then utilize that in daily practice to kind of help evolve that notion of what is cost. But in the bigger picture, I mean, I try to also convey to my trainees that, you know, we as a specialty, if we’re standing still, we are falling behind, right? We have to continue to move forward and innovate. And part of that, and part of the spirit of that is, like I said, trying new devices. You don’t know until you try it. Maybe it can work better somewhere. I’m not saying that that’s the example, to always use detachable coils and not pushable coils, but in terms of new technologies, ablation type, ablation technologies, things like that, right? And then as we go forward from an outcome standpoint, right? And so this is–this gets–you know, I’m an interventional oncologist, that’s what I love to do.

That’s what’s most gratifying to me. And in some of my patients, you know, I’m literally playing whack-a-mole to try to clear the liver of tumor, right? And I’m bringing them back every two months for another procedure. Is that cost effective in the long run? And that’s a whole separate question and topic as well, when we’re talking about innovation and outcomes and, you know, evolving what we’re doing as we go forward. So it’s a challenging space. I can honestly say that I’m not always cognizant of what things cost. Every hospital’s a little bit different. How you’re bundling with a specific vendor is going to be a little bit different everywhere as well. But I like to think that, you know, if I can get it done in the simplest possible way, then I’m going to do it that way. As you said, using a Bentson wire to place a PCNU instead of an Advantage Glide, something like that, right? So it is a challenging space.

Yeah. One of the things, you know, when I’m mentoring young people who are interested in innovation, is talking about the importance of timing. And, you know, right now we are in a cost constrained environment, and that doesn’t look likely to change going forward just for those reasons you already outlined. And so there are lots of things that are great innovations, but if they’re not timely, and no one’s going to–if they’re not solving a currently–a problem that currently paying agencies are interested in, it never happened, right? And so if you truly want an innovation to actually get into practical use, it has to be something that is, you know, incorporatable in today’s society. And so, you know, the classic one, it’s not a medical example, but YouTube–you know a guy named Bill Gross developed what is now YouTube before we actually had the web, so people couldn’t actually use it, and it died because of course it was the wrong timing.

And then when somebody came up with exactly the same thing, subsequently, the timing was perfect, right? And so all of those things happened. So right now, you know, the major, you know–whether we like it or not, healthcare is being rationed, right? Nobody uses the R word, but it is actually happening in both first and third world countries. And so you have to do things that solve problems for those that are holding the purse strings. And so right now it’s just what you said, innovation means something that solves a problem in a more cost effective way. And you have to be able to prove that, right? As well, you know?

So I want to expand on that. So let’s say–and I’m going to use the ablation example because that’s a lot of what I do. So let’s say I have a new technology that can more reliably and safely ablate a central liver lesion, but it costs ten times what a standard ablation system costs. Is that cost effective? I mean, that’s a very small market share, right? It’s providing a safety and benefit and a–you know, outcome benefit–potentially for patients. But where does that cost meet cost effectiveness–and innovate–versus, you know, the need for innovation? I don’t know.

And I think that’s where cost effective studies really play, right? Because you can actually–so it doesn’t mean that any–the one thing innovation does not mean is that it doesn’t necessarily mean it is a cheaper technology in absolute dollars, right? So it could be–upfront be more expensive, but if you can improve survival, if you can improve, you know, the patient’s quality of life–if you can decrease length of stay–I mean, if you think about how much length of stay costs right now, right? If in any way you can show whatever you are doing ultimately reduces the cost–so for–as you said, if somebody–let’s say we have an ablation device where you reliably know on one go you’ve got all of it, right there, the patient doesn’t have to come back the second time around, the third time around. That’s great because A, you’ve improved the patient’s life.

B, you decreased the cost of multiple procedures. I think that’s the argument that’s also being held with Y-90 versus chemoembolization, for example, right? If you can do one and go, you could be more expensive upfront, but less costly in the overall picture. And I think–so to me, innovation really is going to come down to can you show your value? Unfortunately, it’s not going to be incremental changes any longer, right? So one ablation device versus another ablation device. And there are times there’ll be people coming, “Well, you know, I can ablate 3.2 centimeters versus 3.1 centimeters.” I’m like, “That–sorry, not big enough, not good enough for a massive change of inventory or cost.” But as I said, a central lesion, we don’t have anything that does it too well right now. So that would be a game changer because then you’re taking away the patient having a surgical resection, for example, or losing half the liver. Sorry, go ahead Lindsay.

No just–and–but one of those things to tell young innovators about that, just that example you gave–a bigger upfront cost for savings in the future–often the person who’s responsible for the budget that pays for that upfront cost isn’t the person who realizes the savings and the outcome. And so what’s really critical to people doing innovation is actually understanding that, and then setting up your outcomes trials in a way that answers the questions that that other person who ultimately has to wear this, you know, wants, and getting those various stakeholders involved.

And as we are talking about, you know, what are we going to tell future generations? The one other thing that I think is going to be different from Lindsay when you trained, or when I trained, and Kavi probably even for you, is that the political system, the government, is now looking into healthcare, right? It always was, but it just–it just never rose to like topmost priority. Well, unfortunately that has changed in the US. That is going to be one of the, if not in the next five years, in the next ten years, next 15 years. This is going to be a big, big priority for the system, for the government. And so, one thing I would tell all the young innovators is, be comfortable understanding what the FDA does. Be comfortable understanding what CMS does. You have to be involved in the economic part of medicine and the political arm of medicine to be able to actually understand where your innovation’s going to–you know, what are the barriers that you’re going to have to cross, and what are the–what systems you’re going to have to navigate for that to happen. That didn’t happen when I was–you know, 20 years ago. You could get through pretty easily with FDA. I wouldn’t say it was super simple, but it seems to be a lot simpler that time than it is now, right? So again, for the young innovators, get involved with–and I’m putting a shameless plug in here for SIRPAC and the econ committee, because I think the money part of it is getting to be more and more critical knowledge for our trainees.

Absolutely. That’s–those are great points, absolutely great points. And to take that one step farther–I mean, even on government affairs, and now SIR has an FDA subcommittee as well, you know–as we move forward, it’s kind of incumbent upon us to better integrate into the governmental societies. You know, work hand in hand with the FDA to make sure, as we’re approving and evaluating devices, we’re giving recommendations on how that should actually be done for our benefit in the long run.

So in terms of–you know, the big push right now is AI in data. And you know, I haven’t actually seen a practical incorporation of that as yet. Have you guys sort of encountered practical innovations using AI and incorporating it into interventional or minimally invasive therapy, specifically?

Yeah, there were a couple of really good lectures yesterday at SIR. I did one for, you know, mixed reality, and then AI. It’s still young. I think the place where it’s making the most impact is an education, right? And training. So virtual reality–mixed reality, rather–imagine if you can do some of this training without it being on a patient. The other place where–and I think it’s going to be more and more important as they go along, is patient experience. Because patients are getting to be very savvy. You know, My mom’s a physician and I can–and I became a physician because I saw how the patients treated my mom. It’s interesting that that relationship, that doctor-patient relationship, has changed significantly since then, right? Where at that point physicians could say, “Hey, this is what I need you to do.”

And they’d be, “Yes, sir. Yes doctor.” And now the patients, luckily, I think, are more savvy. They know what’s going on a lot more. They can look things up. And so with that point, patient experience is going to be another huge part for virtual reality. And I think as the databases and data overall gets bigger and bigger, I think using AI to identify algorithms and outcomes will again be a big part of it. So I tell my kids, you’ve got to learn how to do this because this is–this is like reading in second grade to me. Like, you know, did you learn how to read in second grade? Yes. Well, in college you better learn how to do AI because that is the way of the future.

Absolutely. And we’re seeing the integration, right? In real time, you know? And so–so my wife is an IR and at Sinai they actually have a computer software algorithm program that picks out the PE–patients with PEs that actually may need intervention–and alerts the PERT team without anybody actually having to do that, right? So that’s a really interesting integration on my side. You know, we–how awesome would it be if I put two probes into somebody’s liver, into somebody’s lung, and they’re not quite parallel and they’re maybe 2.7 centimeters apart, and I have a software algorithm that can tell me what my expected ablation zone is going to be. Reliably, right? And that is–I mean, that’s derived from, you know, data of thousands of ablations. But then having, you know, some sort of software to then evaluate that and predict that and give me what I expect, and allow me to actually, you know, be comfortable trusting that, right?

And we are in that era where that is probably going to happen in the next few years.

Mm-hmm.

I’m anxiously awaiting that. and that’ll change the way we practice. And there are going to be plenty of those things that happen over time. I think as we continue to figure out where the applications are–even walking around the exhibit hall, there are multiple innovations into AR/VR headsets now. Wearing them in the room, I can pull up these cone-beam CT datasets manipulated in real time, you know, with–like in front of my face as opposed to having to go outside to the workstation, you know? It’s–and so it’s rapidly, rapidly evolving. Yeah.

So, Lindsay, have you seen some of the ones where the imaging, I mean, it’s truly immersive imaging, right? And it’s hard to describe on a–by words. And it’s actually even harder to describe in a talk because it’s all still, you know, it’s 2D flat pictures when you’re doing a talk. But I’ve worked with AR/VR companies where it literally can essentially extract that image out and play, you know, rotate it and have a 3D–almost a 4D–visualization of what you’re doing. And to me, one of the things that you learned early on in your training is that preparation is pretty much 90% of that battle, right? If, you know, going in knowing what you’re going to be doing or what that anatomy is, it makes life so much easier than trying to figure it out on the fly. And I think that’s the other place where companies are going to make a big difference. That’s innovation. It is innovation that is going to–what’s the word that I’m looking for? Where it will just change how we do things?

Transformative.

Thank you very much. Right? Transformative, right. It is really that. I think the way we look at images now is going to be–ten years from now, it’s going to be very different from the way we look at it now.

So you’re at Stanford?

mm-hmm.

You know, the sort of epicenter of innovation. Who will pay for that, in Stanford?

Million dollar question, right? And I think it kind of circles back to the same thing, is that if we can show that the patient has to come fewer times because you got a complete ablation, right? You knew right then I am done. One and done, we are all good. That, I think hospitals will pay for, because hospitals are getting crowded length of stays, getting, you know–they want to try and decrease that length of stay. There are more patients they have to take care of than they can actually accommodate. So anything that can help decrease that load upfront will be paid for–anything that increases that length of stay, even if it’s a cheaper version of, you know, it’s a cheaper modality or–So I think that will have a hard time because hospitals are very closely looking at how fast they can take care of patients. The other thing that I think will happen is hospital at home or healthcare at home–there’s a very catchy acronym for that, but–Can we take care of these patients at home so that they don’t have to come into the hospital, so that they don’t have to spend, you know, six days in the ICU? So I think those are–healthcare at home is another big thing to look out for in the future.

So you have a, you know, a trainee come up to you and, you know, “Dr. Kothary, I really admire what you’ve done, all the new things you’ve brought along, and I really want to innovate. What do you think I should be working on?” What, what do you tell them at the current time? Do you see–do you direct them towards devices? Do you direct them towards data? Do you direct them–where do you send them to–a young person that wants to learn?

That’s a loaded question. That’s a very loaded–I’m–it’s tough.

But I think, Lindsay, it goes back to what you said at the very start. What’s the need? What’s the need? What I don’t–you can’t invent a device for the sake of–Like, you can’t invent a device looking for an answer, right? You’ve gotta have your question first. And that’s where I would say, sit down and tell me what you think is the problem. You know, the four why’s, right? Why is this a problem? Why is–da da da? Why–you know, you essentially go through that exercise of, I’m trying to figure out–you know, boil it down to what is the question that you’re trying to answer and what is the problem, and then try and find a–so for—essentially, brainstorm ideas that could be used to fix it. And I think that’s where a younger person has the advantage. Because they’re not–they’re not tunnel visioners. What do you think, Kavi?

Yeah, no, you’re absolutely right. And I try to advise, as well, to just pursue passion, right? So also, you know, more along those same lines, you know, I’m not really a bioinformatics guy, right? So why would I go down that pathway in innovation, right? For me, I mean, I love devices, so I will 100% go down the device pathway and, you know, hopefully not spend too much money, but, you know, go down that pathway. And so–and I think that’s also part of the process. And it’s globally, not just in medicine, you know. I mean, you have preclinical students that come up all the time, you know, like, “I’m thinking about medicine, my–you know.” And I went through this as a child, you know, neither of my parents are physicians, but their dream was always that I went to medical school. Thankfully, I love medicine. I love what I do. So it worked out well for me. But I have many friends that didn’t–that didn’t happen, right? And so, you know, when I talk to high school students, you know, what are your passions? Where do you want to go with it? Always stay passionate, always stay motivated. And use that going forward, you know, don’t just become complacent. Find the avenues that you want to pursue, find the avenues you want to innovate in, and then go for it. Absolutely.

So, Lindsay, I’m going to ask you that question back, because you are actually an innovator. You’ve actually got something to market, right? I don’t know about Kavi. I haven’t got anything to market. All I keep getting to the–is like data and working on–that’s my, you know, bioinformatics is something I do enjoy. So, Lindsay, tell us a little bit about what got you into innovating. What was your journey of getting something to market?

Well, I was really lucky because just through one of those insane sort of set of circumstances, I ended–I found myself ending up in the United Kingdom, working in London as my first as my first consultant position after doing my fellowship. And one of the interesting things at the time was stents were just starting to be used. And it was like the emperor wore no clothes. Everybody–the standard thing was stents have a 2% re-narrowing rate. People didn’t even use the word re-stenosis. And so it was sticking stents–and you could put stents in anybody, and they were all just clogging off. It was absolutely ludicrous. And so you ha–I have that kind of mindset. If I see something, I try to fix it. And so went through all kinds of different iterations, tried making a stent out of different kinds of metal, to create–to make it electrolytic so it would generate a current. That worked somewhat in bile ducts, but not in vessels. And then we made a radioactive stent that had its own kind of issues. And actually then I moved to Philadelphia because there was a guy there who theoretically was doing some of this work. And it turned out he wasn’t. I thought it was actually going to go nowhere, so I moved back to my hometown of Vancouver, University of British Columbia, actually just thinking it as one of those stupid ideas, I’ll never get a chance to sort of see it through. And I went to rounds, a medical student was presenting his summer research on the use of cartilage derived derivatives to treat animal models of rheumatoid arthritis. And I was fully expecting to sit there and sort of, you know, do my work while this was going on.

And this guy had it, he had the answer to what I needed. And so I went up to him afterwards and I said, “You know, I don’t know anything about rheumatoid arthritis, but you do realize this would be the most powerful stent coating ever described.” And he asked me, “What’s a stent?” And so we went and and we bought a basking shark because their cartilaginous. We got 2000 pounds of shark sent to us, and it came just before Christmas and nobody knew where it was. It got shipped to UBC and we came back after Christmas, there was an awful smell in the shipping department. This basking shark had sat at room temperature for 10 days. Anyway, so that didn’t quite go so well. It turned out cartilage didn’t work, you know, it wasn’t powerful enough. And so we, you know, thought, what else has those anti-angiogenic properties that we–we thought we were inhibiting angiogenesis, it turns out it’s the same biological cascade. And anyway–and it turns out Paclitaxel, which is a derivative of the yew tree, which is the active ingredient in Taxol, turns out to be the most powerful angiogenesis inhibitor ever described. And turns out the biological pathway that–that that cascade that happens is exactly the same thing, and so it works at multiple levels. So what I learned from that is just keep an open mind. You never know, right? Opportunity arises. Have a problem that you want to solve, that you feel passionate about. And you’ve got to–you know, there’s–almost nobody really invents something. Like the idea that there’s one inventor is ludicrous because you–no one person, unless you’re making like a tractor clutch or something, really has the knowledge to be able to advance the science. So I needed to work with pharmaceutical scientists.

I needed to work with a guy who understood prolonged drug delivery. I needed to learn about metallurgy with stents and deformability. There’s all kinds of things. And then you had to learn about clinical trials and and how to go through Regulatory. And so really what I took from that is look for those problems. Do it with a–innovate with a pure heart. That’s what I tell young innovators all the time. Solve a problem, don’t do it for the money, and things–everything will fall in place. And then make sure, you know, you have to understand that you have other people and you have to be willing to let them in and help you.

Yep.

I want to point out a couple–that’s an amazing story, first of all. That’s, I mean, phenomenal, even with the shark in the shipping. That’s amazing. So one, I love the point about being a team, right? I mean, I feel like nothing we accomplish today is solo. Everything is part of being a team, and embracing that culture–whether it’s in the IR department, not in the IR department, personal, professional–is I think very important for everybody that’s out there. I also want to know, you know, the IP patent process is a complex process, right? I don’t know that I’m smart enough to have an idea to really take through that, but how was that for you and how has that evolved?

Oh I learned a lot mostly by making bad mistakes, you know? And first of all, you need professionals. What is available now that we didn’t have then is you can do your own basic patent search that’s not bad. You can go on the USPTO site and you can go through it, and then there’s free patents online. And I always encourage people to go through that process and I also tell them, download a patent disclosure sheet. Not that you’re actually going to do it, but it makes you ask the questions that you need to ask. And then–but what’s really important is the patent lawyer will not only tell you if it’s patentable, but they’ll look through it and see what else is out there that’s kind of close and give you an idea about freedom to operate, you know. People–often young innovators are scared of this process and it’s actually the first thing you’ve got to do. I would say it’s actually better now because you–especially in interventional radiology–because there are really good companies that are device specific. When we went–you know, it was a guy who actually–he’d just done a mining–patent in mining and then he came to us. Because that’s kind of how it was at the time.

There’s definitely more resources available now than before, right? But I think it also shows one other thing that people need to have, which is perseverance and patience.

Yep.

There are folks–you know, as with all young people are, right? I mean, I’ve done that where’re like, oh yeah, I got this question, I got this answer, we are ready to go. But any of these things takes–it takes several years and it literally takes a village to try and make it happen because not–we don’t know all the details that we don’t know, right? So I do believe that this is a long drawn out process and you’ve got to have that patience for that. But it’s a very rewarding process, right? I mean, you learn so many more things along the way that you never would have. So I–

And the best part about it is paclitaxel coated devices have gone into millions of–quite literally millions of patients. Like it would take me hundreds of practicing lifetimes, if not thousands–I guess thousands–to actually have an impact on patients. And, you know, that’s something that makes you feel good.

It’s amazing.

You know, so it’s not just the other stuff.

It’s a lifetime achievement award, right? I mean it’s the–

But the interesting thing is–the other thing I’m passionate about is radiation, right? I mean, it’s a crazy thing that we do the kind of crazy things that we do and never think about it. So a company we’ve got going right now is an amazing innovation to reduce the amount of radiation that the patient and everybody else in the room gets exposed to, without degrading the image. And it just speaks to, you know, who’s willing to pay. And so we’ve had this thing going for 11 years now. I wouldn’t say we’re any closer to actually getting into common use. It’s just sort of plodding along. But it shows the difference between–and in fact, we–the people I work with–we know much more than we did the first time around. And yet it’s just, you know, what are–the reality is, is that the hospitals, et cetera, don’t really care about our radiation exposure. They don’t. And mainly because they don’t hear it from us. We’re not refusing to go in the room and say, “We’re not doing that procedure.” Like, we’re goal driven people. Yeah. So it just shows that, you know, you have–like you said, perseverance is important, but–

But interestingly, both companies that you’re looked at–has come–they’ve come from a basic need that you identifed, right? This wasn’t rocket science. This wasn’t like, oh my God, I’ve gotta figure out how to get to the moon, or beyond. These are very basic questions that you answered. It was like, “Well there’s a lot of radiation exposure.” Or, “These stents keep clogging, what do I do?” Right? These are observations, as with all research. Research is essentially observations that you try and sort out and figure out.

Absolutely. Go ahead.

I was going to say the most important word ever heard in the lab is, “Huh.”

Yep. . Exactly.

Well, I want to ask one quick question before we wrap up with our last question. What about things like biodesign programs? What–you know, Stanford has a great biodesign program. When I was at Emory, we worked closely with our biomedical engineering students on their capstone projects, trying to answer random medical questions with, you know, very, very, you know, precursor medical devices. You know, how–when people ask you about things like that, what do you say?

Great question to ask, Kavi, because I can give you firsthand information on this.

Okay.

Because I’m a current biodesign faculty fellow. So they have the biodesign fellowship for, you know, residents and trainees and stuff, but they also have a faculty fellowship. And I think the key part about biodesign is it makes you think in a different way. You may not come up with, here’s my question and here’s how I’m going to answer, right? But it makes you do the process. Like, for example, download the patent form and answer these questions, not because you’re going to be ready to fill a patent just as yet, but it makes you think. It’s like grant–to me, it’s similar to grant writing in that if you have a successful grant, believe me, you’ve at least gone through six versions of that before because you kind of have to fine tune and fine tune and fine tune, right? So I think those things are really important not for immediate realization of your goal of making a device, but really to change the way you think. So I do think these are important programs. And a lot of stuff is actually available online, even just going–so even if it’s not available for you at your institute, a ton of information’s actually available, like on the website.

Yeah.

I think those are great resources.

Yeah. Yep. Absolutely. And you know, not everybody has the opportunity to do something like that, but you know, just with the advent of being able to find things online, online courses, it really opens it up to a lot more individuals out there, especially who are passionate about innovation. Right. So that’s wonderful. Alright, so we’ll wrap it up here in a little bit. So last question: What does innovation look like in the future?

Yeah, I think all those things we just talked about. I think that the kinds of innovation, what people view as innovation is going to be very, very different in the future. How we train people, you know, as you said, you know, using AI to gather what I’m aware of–heart sounds to get–you know, to teach students online, that kind of thing. But also medical innovation is going to be very much about cost containment, I think, in the future. So things have to be cost effective, not just better. As Nishita said.

The common theme, I think–in my view, the theme’s going to be predictability also. It can’t be, well it works this way in one patient and works, you know, in another patient it’s something else and in a third patient it’s something else, right? So you have to be–it can never be–I mean, it would be great to be a hundred percent predictable, but at least much better than what we are doing right now, which can be like, we’ll see what happens. So, right. For example, when we do any local regional therapy, we kind of say, “Well, we’ll wait for three months and see what the results are.” I think that needs to be addressed and answered in new technology. Whatever it is, in whichever field it is in, will have to be reliable, predictable, reproducible.

Yep.

Yeah. Great points. And you know, I mean, let’s look at something like robotics, right? You know, and we’ve seen iterations of robots come through various specialties within medicine, various things outside of medicine, and some stick, some don’t. You know, I think the outcome measures are going to be very important. The cost measures will be very important. And it’s a–you know, to be honest, to me it’s a little bit of a black box because I don’t know–like, you know, we–one of the things I try to tell my students and fellows is–you know, again, you don’t know until you try something. But I can’t conceive and conceptualize what innovation is going to be in ten years. What are the new devices,? What, you kno– maybe we’re not working in the lab and, you know, remotely controlling something like we’ve, you know, seen potentially in the past–or sometime in the past. And we’ll continue to see that evolve over time. I can’t conceptualize what it’s going to look like in 50 years, a hundred years, you know. Maybe we’ll have a magic pill that, you know, that will obviate the need for local regional therapy. Who knows, right? So it’s going to be interesting to watch it all evolve and I think it’s going to be a very enjoyable ride.

Yep. Stay hungry. Yeah. That’s the motto, right? And I think IR is well suited for that because by definition we tend to be curious, hungry people. We’ve had to–you know, we’ve come up with new therapies, new modalities, so I am excited for the future of IR in that I think we are hungry a lot.

And collaborative.

And collaborative, exactly.

I think that’s–you know, I think that’s really a big part of what we are. Like the three A’s of practice, you know, availability, ability, and then approachability. But I think also appreciation. The fourth A is really important. And I think IRs have that and that’s one of the reasons why we will always be there and be part of it. Yeah.

Where else can you be at a national conference and reach out to anybody, in any program, and just walk up and shake somebody’s hands, right? That is truly nuanced to interventional radiologist. I’ve never seen that in another specialty and something that I hold very near and dear to my heart.

And you’re standing on the shoulders of giants, so thank you so much. With that, I–this is a wrap. Thank you, Kavi. Thank you, Lindsay. This has been fantastic and I hope our audience enjoys this conversation as much as I did. Thank you again.

Yeah, awesome time. Thank you all.

Thank you.