From academia to innovation: Dr. Christoph Binkert on building Switzerland’s first outpatient IR clinic

Episode Transcript

Behind every case, there’s a story. Behind every story, there’s a lesson. And behind every lesson learned, there’s a trusted mentor. This is Prepped and Draped with Dr. John Kaufman, where candid conversations, actual cases, and bold new professionals shape medicine.

Hi, it’s John Kaufman. I’m here with the Prepped and Draped podcast talking to my good friend Christoph Binkert, who is one of the premier interventional radiologists in Europe, former president of CIRSE, the Interventional Radiology Society of Europe, a chairman of a department. We’re going to be talking about a couple of interesting things.

Welcome, Christoph. Why don’t you introduce yourself?

Hey John, it’s great to see you virtually. I’m Christoph Binkert. I’m an interventional radiologist from Zurich. I trained with John Kaufman at the Dotter Institute in the year 2000 until 2002. Then I was a associate professor at Harvard Medical School working at the Brigham and Women’s Hospital. Then I came back to Switzerland, and I was for 17 years chairman of radiology, and especially interventional radiology, at a great bigger university-associated hospital in Winterthur. And for a little bit more than a year, I’m working in a, you call it an OBL. I think for us it’s more like interventional radiology clinic in Zurich.

So Christoph, I think there’s a pattern there that you’re a person who’s not afraid of change and challenge. Just start talking about what it was like to start in Europe, come to the US and train, practice, and then go back to Europe.

What were some of the challenges moving in these different environments? And not only for you, but for your family.

All right. I think that one of the biggest things I didn’t realize at the beginning was the language. I spoke relatively okay English when I came to you. Important, but it was extremely hard for me to listen the whole day because at the beginning you’re translating every sentence, and that was really tiring a lot. It took me a couple of months, let’s say one to three months.

For example, the word pneumonia, I was not aware what that means until I saw it once written. These are the things at the beginning make it hard. The other thing is hard that the workflow is slightly different from country to country. And so, it takes a while until you adapt to that. But once you have it, it’s enriching.

I think it really opens your mind, but at the beginning you have one way of doing things, and then you go to a different environment, and it really is a big change. That’s for me, professionally. The family, of course, they have to follow. I had a very young boy at that time. For the children also, the change of language was more difficult at the beginning than I expected. It doesn’t take them long, but at the beginning they felt lonely because they could not communicate outside the family. And of course, you need a loving wife to do all this with you.

Tell me a little bit about the working in different healthcare systems, the things that you’ve found maybe a little bit challenging and also maybe things that you thought were advantages to each of the systems.

That’s a very good question because at the end of the day, I don’t think there’s one good system. They have pros and cons on both sides. I think that the best thing is that if you are exposed to different system, you start to realize and find the best ways on either of them. It’s not so simple to just say, “This is good, this is bad.” In the US, I would say at that time it was, for interventional radiology, much more clinical than it was in Europe.

So, I really had to learn from the beginning to really take care of the patient. I think you were a great role model on that. This was a big change because at that time in Europe, interventional radiology was more like a diagnostic service. You got a request to do a procedure, and then you performed the procedure, but didn’t see the patient afterwards or beforehand. And that the doctor was already there, that you actually see the patient as a fellow, you would round and be much more clinical, which was a big change.

All the big change was also slightly different medication, which was at the beginning a challenge. Of course, they were similar, but they were different. Also the lab, the parameters on the lab and the units are different. These are simple things, but at the beginning you were kind of off with that. At the end, you adapt to this. It was much more clinical, it was more standardized in the US than it was in Europe. That was a big help for me coming back.

I think the biggest advantage is if you go out of your environment, be in a different environment and then come back and then maybe make a fusion of the two systems and use it as your advantage.

Maybe the advantage of being eclectic, taking the best of all the different experiences. Let’s talk a little bit about the clinical practice. I know you’ve been a champion of clinical practice in general, particularly in Europe.

How’s that been going, getting people to adopt that model that you were practicing when you were over in the United States?

I wouldn’t call me a champion. I would more say I’m very passionate about clinical care. I think it’s very important. I think for me it was one of these highlights— or it’s not highlights, but these moments of truth.

When I was at the Brigham and Women’s Hospital, we did a lot of peripheral vascular disease work, and we didn’t do any clinic at that time for this part of disease. Then the endovascular surgery took over. Very friendly, it was not even a fight, but they just did it themselves and we dropped the numbers. We had about four to six cases every day, which were lacking.

I learned that if you just wait for a referral, then that can go away really quickly. So, I thought to myself, we should really change that and really take care of the patient, not just for not losing things, but really because I feel that’s the right thing to do, and that’s why I’m more passionate than champion. Since then, I’m really doing this and I think this was very helpful.

I came back to Switzerland, and at this time when I came back, no IR did that. So that gives me a huge advantage, and people felt that I’m a pioneer, but that in fact I just copied the US system and introduced it to Switzerland.

That’s hard work to add that on. How did you manage doing that in a system that wasn’t designed to have you function that way, and then you wanted to change how that happened? What did you have to do to be able to practice the way you wanted to practice?

That is actually— It was really a lot of work. Initially, when I start doing clinic and that was clear that I will do that, luckily as a chairman of a department, you have the power to say, “I will do this.” Initially, I got a lot of opposition from my clinical colleagues. They felt that’s their thing and I should do the procedures only. For me, it was clear I can’t do that.

Initially, they made me do it in my spare time without billing for it. I did this for about a year. It starts to be more and more accepted by my colleagues. Then I remember that I had to go to the hospital director, and I had a very good relationship with him, and he told me, “Look, I heard about you doing clinic and seeing patients,” and I said, “Yes, I’m doing this.” I was kind of in the defense mode because I felt people may say, “I don’t want you to do that.”

But the conversation turned quite interestingly. He said, “No, no, I’m happy you do that, but I heard you’re not billing for it.” I said, “Yeah, they told me I cannot do that.” He said, “No, no, no, you stop that, and from now on you have to bill for your service.” That was kind of a funny moment, and from then on it was established. Really interestingly enough, the initial— especially for example, the oncologist, which became a really good friend of mine, felt that a radiologist is not doing this.

He was kind of afraid it was not done properly. He was against it at the beginning, and later on he was the biggest promoter. He said, “Look, I have an IR who actually explains everything to the patient directly.” So it was really this change was very big, but at the end it turned out to be very well-accepted and actually very much liked by the other clinicians.

Yeah, I don’t think there’s any procedural specialty where it’s not to the benefit of the patient and the care that the proceduralists has a big role in explaining the procedure, seeing the patient before, and following up. Nice to hear that that holds true.

We’ve been talking about the advantages for you. How about for your family? Were there things that you think were a benefit to them to having had these experiences living, growing up? You had a couple of kids while you were here, and so you expanded family while you were here?

Yes, it was a good environment for me, the US. I really have to say, for the family it’s much more difficult because for me, day one, July 2nd or 3rd when I started with you at the Dotter, I had another environment, which was very interesting for me. It was absorbing my energy, and I was able to find people like-minded. For the family, it was much harder, especially for your wife, finding some connections.

We were very welcomed here in the US, but it was at the beginning a little bit hard, especially with one young child. It was hard to find connections. It took maybe half a year to overcome that, especially because my wife is extremely social, so she likes to have company. That was a little bit hard at the beginning, but I must say at the end it turned out to be a super experience and we will not want to miss it because it really strengthened the family ties because we were very close at that time.

I mean, we are still close, but it was extremely because there was very much we did together without distraction. And so, I think yes, it was a huge benefit, but the start was way harder than when you work.

So it’s a risk right to go a quarter of the way across the world in a totally different environment to start over, but it sounds like you made the best of it both personally and as a family.

Let’s talk a little bit about your recent change. Again, the theme that you’re not afraid of challenges and you’re always looking at changes. You were a department chair for 17 years.

Correct.

By that time, you’re a part of the fabric of an institution. You’re very well established. What made you think that you wanted to try something different?

I think John, you just mentioned that. I think I tend to be someone who likes challenges. Not that it was not challenging for being a chairman at the relatively large radiology department. It was just at that point it was for me, a cross way because the workload, the department grew from about 70 employees to nearly 200. So, the management tasks became bigger and bigger.

I still wanted to be very active as an IR, and it turned out to be not possible really to do both of them. I had to make a decision to really focusing more on management or doing more IR. Both things together at this chairman position wasn’t really possible. I mean, I worked very hard, but at some point it was clear, you have to change. It turns out for me that I realized that what I really like to do best is treating patients and working as an IR. I think that was the point.

Then also, again, after 17 years, I was in the mid-50s. You have to decide if you change now, that’s the time, or you stay on, which was an option which would be okay for me. But I thought the challenge to do an IR clinic, really walk the talk, what I always said, “I’d really like to try that.” I was lucky enough to find some very good, old friends of mine, which I went to med school with that they actually wanted to embark with me on this risk and this journey to do that.

So yeah, the term in US is OBL, office-based lab, or surgical centers, and it’s going to be a little different across the world. How did you decide to go with your friends? I imagine there were a couple of options for how you could have done this if you’re thinking, “Well, it’s time for me to try something new.”

How did you evaluate the different options? People don’t know it, but you have an MBA, so you may claim you don’t have a lot of sophistication, but I know you are. Tell us a little bit about how you chose to go the particular way you did.

Pretty much there are two big options. One option is you go to a private hospital and be a part of this hospital, but then you’re back in a bureaucracy, and IR is not yet established so much as a clinical specialty. I was not sure I wanted to go there. Actually, I didn’t want to go there. You do it totally by yourself. I have to say it’s not just the equipment and the staff, but you also need an IT, you need a PACS system, you need anything.

It becomes a real big thing. So be part of a well-established high-level diagnostic radiology group, which also is very innovative. They were the first to have their own nuclear medicine department or group. For them, it was interesting to widen their scope and have a newly, new in IR, within them to get these services on board. For me, it was really a win-win.

I was able to really benefit because if you think about when you do your clinic, like say I do two and a half days consultations, you can have— with this imaging group, I have access to MR, to CT, to all imaging modality, PET CT, everything I want. This was really, really helpful for me on that side. For them, it was kind of interesting to have an interventional radiologist who is actually able to build that branch up.

I think it worked out well, and I have to thank them to embark that because so far there was no model in Switzerland to doing this.

There’s always risk with something new. What are the risks that you thought you were facing by doing this?

I think the biggest risk, it also was how you get patients. Because if you work in a hospital, especially in a large public hospital, a lot of patients, they come through emergencies, through colleagues, they come to you and then you can, of course, discuss it with them and then do your procedures.

If you have your own independent interventional radiology clinic, no patient stumbles in the door and says, “Here I need a procedure.” It’s really, you have to have consultations. You have to have a network that you actually known enough that people trust you with their patients and send it to you and so you can find the patients. I was always afraid. Then interestingly enough, it was very different.

Some people promised me a lot to send me everything. I didn’t get any referral from them. And others, beforehand were rather critical, embarked in a great relationship. That was kind of interesting for me. Then what I really learned is the best ways is not B2B, to speak in a little bit of management terms, but B2C. So make sure patients can come directly to you.

This has shown to be really the key, that patients who are happy are the best promotion you can do because they speak to others and it starts to evolve. This is what happens right now.

I’ll challenge you a little bit, and that sounds to me like you’re still doing a lot of work on managing and business planning, and so not just 100% clinical. There’s a lot more to this than just doing clinical procedures.

Yeah, you’re right. I told you I like that. The point is now we have a— Of course, the entire group is about as big as the department beforehand. It’s run by 10 owners, and we take shares. We really— It’s different. It’s not a hierarchy, it’s a flat curve. It’s a flat group. These 10 have their jobs to work together, and my job is really to get the IR up and running. And so, my core team is that eight people.

The whole leading people, which is very time consuming, it’s much more reduced. It’s a very small team. And so, the management is there, but it’s more like on a daily basis it’s very operational and you don’t have to real`ly work on strategic things. A lot of meetings, that’s very much reduced. So yes, managing, but on a more operational level.

So you don’t have to have meetings to plan the meeting, and then meetings after the meeting to evaluate the meeting?

Exactly. Then try to influence others to lobbying to get people, because we are the 10 of us and we make quick decisions. Of course, you have to convince them it makes sense, but because the group is much smaller and we are all in there, yes, you feel very quickly and it’s very simple to convince them if it’s a good idea to go very quickly. Then you re-evaluate quicker too. If you see this is not going to work well, then you maybe change directions, but it’s much, much faster pace than in a large hospital.

That’s a common theme when you talk to people who have made this transition that think it’s easier to make decisions, easier to change things, much less bureaucracy in order to do things.

Do you think you could have done this when you came back from working in Boston, gone directly into this environment? Or do you think you needed at least some of the time that you had working in the hospital system? I’m asking for the people who are out there thinking, “Oh, I’m thinking about this as a career move.” When’s the right time to do this?

I think this is the difference between the US and Switzerland because nobody did it in Switzerland, to my knowledge beforehand, that step. I think it was extremely helpful to have a good network and also to be recognized as someone who does the job right. I think I couldn’t have done that directly coming—especially not coming from out of the country. You need the network in there.

Now obviously, once OBLs or free-standing IR clinics are more known and this model exists, I think you can potentially go quicker. I think, however, the big difference is you don’t have the hospital backup, and I think you really depend on your skills, your judgments. I think you have to have a level that you kind of minimize complications as much as possible. I think you need a certain amount of years in a hospital setting.

At least for me, that was extremely helpful. And I didn’t want to miss it either, so I had a great time. It was not a bad thing at all. So I think yes, it is not just out of fellowship going out. I think it is helpful to get to use things and to be able to manage your patients independently. I think that needs some experience, yes.

How do you choose what to do? The hospital, you just do whatever comes along, whatever people need you to do? There’s varying levels of acuity. You’re in a different situation where you can be very selective, and like you’re saying, you need to do things that maybe have lower probability of a complication.

How do you choose what kind of cases to do? Tell me a little bit more about that.

That’s very good, John. I think honestly two things. You have to choose your patients well. I personally think it’s not necessarily the procedure because most IR procedures can be done in an outpatient setting. It’s really choosing the right patients. If a patient has is multi-morbid with many, many problems, these patients should go to a hospital. I think they’re not right in an OBL-type setting. The patient needs to walk in. That’s why I always call it the ambulatory sector. If they cannot walk to you, then maybe they’re too sick to be treated in this environment,number one.

Number two, I think you have to be, as I said, a little bit opportunistic. I thought, for example, dialysis work would go really well here. It turns out though that the dialysis in Switzerland is really tied to hospitals, so they usually send it to that hospital no matter what. This was very difficult. We just do a few things like that. If you bring in new procedures, I think that’s the best way you can enter the market.

For me, one of the luck or the opportunities was that I was very interested in the MSK embolization early on. I went to Yuji Okuno for about two weeks to study that.

MSK meaning musculoskeletal, just for those not—

Oh, sorry. Yes, musculoskeletal embolization for osteoarthritis or chronic tendonitis. I was kind of the first, not the very first. I mean everybody did it a little bit, but I was someone who really focused on that, and that gained momentum because I started to really working on this. That turns out to be very, very helpful. Embolization procedures, they are ideal because they use typically very small access points. That was one of the things.

Then also, prostate artery embolization was something that really worked well because I go often radially, so they done very well on an outpatient setting. UFE, I also perform, but the whole pain management afterwards can be in an outpatient. It works, but it is a bit challenging because you have to deal with that. So it’s not super ideal. I still kept some peripheral vascular disease. I’m very happy about that from some colleagues who sent me that before and trusting me their patients.

This is still a relatively big part in my practice. Then it turns out with the MSK embolization, I got very well-connected to sports medicine, orthopedics. So, I also do quite a bit of vertebroplasty on an outpatient setting, which is very well-accepted by the community.

I’m sure you’re thinking about the next thing that you’re going to bring in, or the next potential procedure or patient group that you’d like to start treating. Can you share any thoughts, or is it top secret so you can’t?

No, it’s not top secret. I share everything with you, and you know me really well. That’s exactly the focus I have. I think when you start, you have to be a little bit open. If you just say, “I do this,” then that may be difficult to do. Obviously, the more your practice is established and mature, you will start to have focuses.

The next big focus I’m working on is cryoablation of the breast. That’s not done on a regular basis in Switzerland yet. I was with Franco Orsi, also a good friend of mine in Milano, and I think this is an excellent outpatient procedure with excellent results. This is what we will start in the next weeks.

This will be for cryoablation for malignancy?

Yes. Cryoablation for breast cancer. Obviously, you want to select the patients well, so it’s 1.5 centimeters and uni-locular disease. We will do an MR beforehand. You will also need to take a histology for future therapy. But I think this is something that could be potentially very, very helpful. Again, this is not yet done on a larger scale in Switzerland, so I see this as an opportunity.

As always, I know you’re always thinking ahead and, yeah, that is a very interesting emerging field for image-guided intervention. Good luck with that, and congratulations. Christoph, thanks so much for this conversation. I really enjoyed it. I always learn something from you. You may think that you learn from me, but the secret is we learn from our students and they become our teachers over time.

Thank you very much for the conversation and enjoy the rest of your evening.

I will. Thank you very much, John. I was happy to be a guinea pig for your show here. Thank you.