Vascular Surgery Interviews

Interview #1 Conducted by 2001-02 Division Coordinator, Reza Sanai (George Washington U.) Dr. Bruce A. Perler

Biography: Dr. Bruce A. Perler is a Professor of Surgery at Johns Hopkins University Medical School. He is the Director of the noninvasive laboratory and an attending vascular surgeon at Johns Hopkins Hospital. He attended Duke University for his undergraduate education where he majored in zoology. He also attended Duke University Medical School. He completed his surgical internship and residency at Massachusetts General Hospital where he also completed a clinical and research fellowship in vascular surgery.

Do you have any particular interests within vascular surgery? Cerebrovascular What attracted you to vascular surgery? An interest in cardiovascular disease and pathology Throughout your training, what has been the hardest thing to deal with? Patients that don't do well How would you classify the competitiveness of obtaining one of the fellowship spots in vascular surgery? Moderate Do you have any suggestions or advice for premedical or medical students considering a career in vascular (or surgery in general)? Find a really good mentor Do you have any particular memories from your fellowship that you would like to share? Camaraderie with general surgery residents What would you say is the most common medical condition you treat? Atherosclerosis What would you say is the most challenging problem seen by surgeons in your field today? Thoracic abdominal aneurysms In 15 years, where do you see vascular surgery? Largely catheter-based and medically-based therapies What do you see as the three most important advances in your field over the past 25 years? Endoluminal stent grafts Small vessel anastomosis Critical care What do you see as the three most important advances in your field over the next 25 years? Genetic engineering Catheter based treatments New pharmacologic treatments Throughout your career, is there a particular case that stands out in your mind? There is not one case in particular that I can speak of.

INTERVIEW #2 Conducted by 2001-02 Division Coordinator, Reza Sanai (George Washington U.) Dr. Thomas G Lynch

Biography: Dr. Thomas G Lynch is a Professor of Surgery and the Chief of the Section of Vascular Surgery at the University of Nebraska Medical Center in Omaha, Nebraska. He is affiliated with both the University of Nebraska Medical Center and the VA Medical Center. He graduated from John Carroll University with a major in Biology. He completed medical School at Georgetown University where he also did his surgical residency. He trained in vascular surgery at the University of Iowa.

Do you have any particular interests within vascular surgery? Vascular noninvasive diagnosis Diagnosis and treatment of deep venous thrombosis Diagnosis of carotid occlusive disease Computerized educational models What attracted you to your specialty? I found the ability to tackle varying problems within a focused area of specialty to be attractive. Most vascular problems can be broadly categorized as carotid, aneurysmal, vascular occlusive or venous. Within these focused areas, however, the spectrum of pathology is broad and presentations varying. Throughout your training, what has been the hardest thing to deal with? Change, while not the hardest thing to deal with, has certainly been the most challenging. The diagnosis, as well as the treatment of vascular disease, has changed significantly in the past 20 years. In the early 1980's noninvasive diagnosis was made using indirect techniques, which reflected the hemodynamic consequences of vascular occlusive disease. Over the last three to five years, magnetic resonance imaging and magnetic resonance angiography have expanded the scope of noninvasive diagnosis to provide three-dimensional images of the arterial circulation. Therapeutic options have also expanded to include interventional techniques such an angioplasty and endoluminal therapies. All of this change has occurred against the background of increasing government and third party regulation and documentation. Some of the changes have clearly been beneficial as they provide increasingly better data and documentation. Some changes have clearly resulted in significant volumes of redundant paperwork without benefit to the physician or the patient. How would you classify the competitiveness of obtaining one of the fellowship spots in your specialty? Above average to high. Do you have any suggestions or advice for premedical or medical students considering a career in this specialty (or surgery in general)? For medical students considering a career in surgery, I would suggest that they review the surgical prerequisites defined by the Graduate Medical Education Committee and the American College of Surgeons. These define objectives that students should attempt to achieve prior to leaving medical school that would provide an appropriate background for a general surgery residency. http://www.facs.org/about/committees/csems/welcome.html http://www.facs.org/dept/serd/gmec/prereq.html For those considering further specialization in surgery, research and experience are clearly beneficial. This should be at least one year, if not two years in duration. Do you have any particular memories from your fellowship that you would like to share? Somehow starting work early in the morning and ending late at night did not seem quite an onerous as it does now. Training at an institution where new technology or procedures are under development is clearly an adventure and can be an exhilarating experience. What would you say is the most common medical condition you treat? As I mentioned above, vascular surgery tends to be compartmentalized into the treatment of carotid, aneurysmal and peripheral vascular occlusive disease. Patients with carotid disease include those found to have an asymptomatic carotid artery stenosis or those patients who have had a stroke or transient ischemic attack, with subsequent evidence of internal carotid artery occlusive disease. Aneurysms may involve the aorta and peripheral arteries. Patients with evidence of aortic or femoral popliteal occlusive disease often present with symptoms of claudication or rest pain. What would you say is the most challenging problem seen by surgeons in your field today? From a practice standpoint, the most challenging problem faced by vascular surgeons is the necessity to remain current with new technology. Having been trained in the new technologies, there is the further challenge of working with colleagues in the fields of radiology and cardiology, who are also developing similar skills, particularly in the area of interventional management of vascular disease. From a technical standpoint, "re-do" surgery in patients who have had previous reconstructions or interventions is probably the most challenging activity. It is challenging from the pure anatomic standpoint of dissecting and laying out the appropriate anatomy and pathology, and also from a resource aspect of finding autogenous materials, which can be used to rebuild occluded vessels. In 15 years, where do you see your subspecialty? In fifteen years I would see the vascular surgeon functioning as a diagnostician, interventionalist and surgeon. Vascular surgeons have traditionally been actively involved in the diagnosis and medical management of peripheral vascular disease. Recently, in addition to the operative management of vascular disease, vascular surgeons have become involved in catheter-based interventional technologies. I would suspect that these skills will become increasingly important as a supplement to the operative management of vascular occlusive disease. What do you see as the three most important advances in your field over the past 25 years? I would see the introduction and use of ultrasound for the noninvasive diagnosis of vascular disease as the first important advance. Recently, magnetic resonance angiography has made great strides in noninvasive visualization of arteries and veins. This clearly is the second most important advance. This has the added advantage of providing three-dimensional visualization of a vascular occlusive process. Traditional angiography has been limited to two or three views of a particular area because of the risk of increasing dye load. The most recent advance in vascular surgery has been the introduction of interventional techniques. These have provided less invasive ways of treating certain occlusive processes of the aorta and peripheral arteries. Current interest in endoluminal grafting will provide additional options in the treatment of aneurysmal disease. One challenge presented by new technology is the necessity for unbiased assessment. It is important to have a plan for the evaluation and introduction of technologies. Recent problems with the newer endoluminal technologies highlight these concerns. What do you see as the three most important advances in your field over the next 25 years? I would suspect that the advances over the next 25 years will include greater strides in the medical management of those disease processes that predispose to vascular occlusive disease including hypertension, diabetes, hypercholesterolemia and genetic predispositions. I would see greater use of molecular biology in the treatment of vascular occlusive disease. The introduction of such molecular technologies may be complemented by interventional or catheter-based delivery methods. Finally the introduction of robotic surgery or minimally invasive surgery will provide an adjunct or alternative to the endovascular surgery currently being developed. Throughout your career, is there a particular case that stands out in your mind? Every case is unique because of the individualities introduced by the patient. These may be anatomic variations, as well as the individualities related to unique interactions with the patient, his personality and his family. Do you have a case report you can share with me that you feel would be of particular educational value to the other students? One that comes to mind is a musician in her mid-thirties, who presented with the acute onset of left arm pain. Her past history was relatively unremarkable except for the diagnosis of a right deep venous thrombosis four months prior to presentation. The patient was found to have a left brachial artery embolus. Subsequent work-up demonstrated a patent foramen ovale, suggesting that the patient had presented with a paradoxical embolism from the right deep venous thrombosis. Do you have any suggestions for specific areas for me to focus on as I develop material for the other students? I would suggest looking for case materials and operative descriptions of those common procedures such as carotid endarterectomy, abdominal aortic aneurysmorrhaphy and peripheral vascular reconstruction. It would also be important to explore some aspects of venous disease, which is often not covered well in medical schools. http://www.vascsurg.org/ http://www.dvt-info.com/ I would also include a discussion of the use of endovascular technologies and some of the current problems experienced in the introduction of those technologies. I would explore the increasing overlap between specialties including interventional radiology, cardiology and vascular surgery. I would look for discussions of the role of molecular biology and genetic manipulation in the treatment of peripheral vascular disease.

INTERVIEW #3 Conducted by 2001-02 Division Coordinator, Reza Sanai (George Washington U.) Dr. Thomas Brothers

Biography: Dr. Thomas Brothers is an Associate Professor of Surgery at the Medical University of South Carolina and is affiliated with the Charleston Veterans Hospital. He attended Kalamazoo College where he majored in health sciences. He completed medical school, surgical residency and a vascular surgery fellowship at the University of Michigan.

Do you have any particular interests within vascular surgery? Lower Extremity Disease, Renal and Mesenteric Disease What attracted you to vascular surgery? Types of operations and patients Throughout your training, what has been the hardest thing to deal with? Encroachment of traditionally vascular surgical interventions by non-surgical interventionalists How would you classify the competitiveness of obtaining one of the fellowship spots in vascular surgery? Very Competitive Do you have any suggestions or advice for premedical or medical students considering a career in vascular (or surgery in general)? Make certain that you understand the lifestyle and time commitments. Do you have any particular memories from your fellowship that you would like to share? No thank you. What would you say is the most common medical condition you treat? Limb-threatening ischemia of the legs, especially related to diabetes mellitus. What would you say is the most challenging problem seen by surgeons in your field today? Temporary nature (palliation, not cure) of interventions for vascular disease. In 15 years, where do you see vascular surgery? Much more minimally invasive, fewer open operations What do you see as the three most important advances in your field over the past 25 years? Development of operations to treat advanced disease of lower extremities, treatment of thoracoabdominal aortic aneurysms, proof of benefit of carotid artery surgery in reduction of risk of stroke. What do you see as the three most important advances in your field over the next 25 years? More minimally-invasive interventions for vascular disease, better understanding and methods of prevention of vascular disease, prevention of failure of intervention (intimal hyperplasia). Throughout your career, is there a particular case that stands out in your mind? Many, many, many good ones. But the operative deaths are never forgotten. Do you have a case report you can share with me that you feel would be of particular educational value to the other students? Not at this time in this forum. Do you have any suggestions for specific areas for me to focus on as I develop material for the other students? Possible future of a combined specialty of vascular surgeons and interventional radiologists/cardiologists as a endovascular specialist.

INTERVIEW #4 Conducted by 2001-02 Division Coordinator, Reza Sanai (George Washington U.) Dr. Vic Weiss

Biography: Dr. Vic Weiss is an Assistant Professor of Surgery at the Emory University School of Medicine. He attended the University of Richmond where he majored in biology. Following that, he attended medical school at New York Medical College and completed his surgical residency and vascular fellowship at Emory.

Do you have any particular interests within vascular surgery? Endovascular, venous disease - We basically "do it all" however. What attracted you to vascular surgery? Several things… At a time when I wasn't exactly sure what I wanted to do, but knew I liked general surgery, Vascular was the one fellowship that opened more doors than it closed. The ability to do open surgery and minimally invasive procedures means that you can do it all. The aging population will mean a steady stream of business. The technical aspects of the surgery are challenging and fun. The field is rapidly changing, with exciting new technology. My only other real consideration was cardiac, and I felt that there were many shortcomings of that field, for me personally. Throughout your training, what has been the hardest thing to deal with? That's easy. I got divorced during my third year. Worst thing I have ever experienced by a long shot. No big fights, no not getting along. Basically, my wife at the time finally understood that being a doctor was not going to be a job, but a profession and a major commitment. She knew she couldn't/wouldn't deal. I've since married a doctor who has a more understanding view of a doctor's life. How would you classify the competitiveness of obtaining one of the fellowship spots in vascular surgery? Surgery overall is seeing a decline in applicants. Unfortunately, for many of the surgical fellowships and for general surgery itself, there are more spots than applicants. If you want a spot, you got it. That being said, there are big differences between the best and the worst fellowships. I am active in screening applicants and the review process. Research helps applicants stand out in a crowd. Do you have any suggestions or advice for premedical or medical students considering a career in vascular (or surgery in general)? See as many of the other fields in medicine that you can, surgery and otherwise. Know in your heart that this is what you want. It WILL get in the way, with your free time and with family life. You never want to have to question your career choice. The challenge is finding balance in your life. Do you have any particular memories from your fellowship that you would like to share? Professionally, the greatest year of my life. Having a great group of surgeons bring me their cases to do everyday (the cases I always dreamed of doing) while working in a very friendly environment was more than I could have asked for. What would you say is the most common medical condition you treat? Dialysis access, lower extremity ischemia, aortic aneurysms and carotid disease What would you say is the most challenging problem seen by surgeons in your field today? Overall, it is judgement. Example: 85 year old with an AAA (6cm), heart disease and COPD. What do you recommend? Open aneurysm repair (a well established standard of care), endovascular repair (considered experimental by many with unknown long-term outcome) or observation (potentially risky). It gives you an opportunity to use your judgement, and talk with the patient and the family about their wishes, etc. A technically demanding field where you are challenged judgmentally as much as technically. In 15 years, where do you see vascular surgery? I am just back from our national meeting, where this question was debated in a way. Our wish is to be the leaders in the field of peripheral vascular disease, the only specialty able to look at a patient and their arterial disease and to be able to treat it/them using either open or endovascular technology or a combination. This means treating patients based on what is best for them, not what is best for your wallet. What do you see as the three most important advances in your field over the past 25 years? It's recently been said that there has been more advance in vascular surgery in the last 50 years than in the last 2000 before that. 3 advances: Transluminal therapy (Dotter and Grunzig) leading to balloon angioplasty, stent, etc. Aneurysm treatment via endoluminal approach A combination of improvements in critical care, including epidural analgesia, enabling many patients to better tolerate big open procedures What do you see as the three most important advances in your field over the next 25 years? Hopefully, a treatment for neointimal hyperplasia (could revolutionize the field), A method of hemodialysis other than how we are currently doing it, and to develop a way for people to either never begin smoking, or a better treatment to assist with smoking cessation. Throughout your career, is there a particular case that stands out in your mind? Only the bad ones…Give it a few years, and you'll understand. Do you have any suggestions for specific areas for me to focus on as I develop material for the other students? I think that what draws students to a field initially may be mentors in the field. I know that at the vascular societies, we are always discussing ways to attract the best applicants. There has been talk of limiting the years of training, though nothing is set in stone. Perhaps having a nationally based "Vascular Mentorship", the recognized leaders in the field could be identified at the various medical schools, and paired up with a medical student. For instance, I recall being shy about going up to a doctors in my medical school and striking up conversation, or asking to go into the OR with them. Perhaps it might be easier for students to write in and identify themselves via the AMSA website. Then the "vascular-AMSA advisor" could contact someone at that student's medical school to alert them that the student exists, that they have expressed an interest in vascular surgery, and encourage that surgeon to take the student "under their wing". I think that forming those relationships will go a long way. Give me your thoughts.

INTERVIEW #5 Conducted by 2001-02 Division Coordinator, Reza Sanai (George Washington U.) Clyde F. Barker

Biography: Clyde F. Barker is the Chairman of Surgery at the University of Pennsylvania. He attended Cornell University where he majored in Zoology. He also attended Cornell Medical School. He completed his general surgery residency and vascular fellowship at the University of Pennsylvania and he has additional training in Transplantation Biology.

What attracted you to vascular surgery? Chief of Vascular Division Throughout your training, what has been the hardest thing to deal with? Interpersonal relationships How would you classify the competitiveness of obtaining one of the fellowship spots in vascular surgery? Moderately competitive What would you say is the most common medical condition you treat? Aortic aneurysms What would you say is the most challenging problem seen by surgeons in your field today? Role of endovascular treatment of vascular disease What do you see as the three most important advances in your field over the past 25 years? Improved imaging - CAT, MRI Angioplasty and interventional radiology Vascular laboratories What do you see as the three most important advances in your field over the next 25 years? Endovascular surgery, treatment and prevention of arterioslerosis Throughout your career, is there a particular case that stands out in your mind? Renal transplant