Balancing scalpel and family: Dr. Kendall Endicott on building a career and life in vascular surgery

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, I’m John Kaufman. I’m really excited to be talking to Kendall Endicott, Dr. Kendall Endicott, who is a early-career physician and has some really interesting perspectives on that. Kendall, why don’t you introduce yourself?

Thanks, Dr. Kaufman. I really appreciate you guys having me here today to chat. I am a vascular surgeon in northern Virginia. I’m originally from Indianapolis, but moved out to the DMV following my husband for residency. He’s a gynecologist in the US Army, and we’ve now been out here on the East coast for 14 years and aren’t going to leave. So trained at GW, George Washington, for general surgery and University of Maryland for vascular fellowship, and I’m now in northern Virginia. I know the health systems.

Kendall, the first name basis, you’re from Indiana. I’m in Indiana right now. So it’s all pretty relaxed.

Go Hoosiers.

Go Hoosiers, yeah. So when we first talked, I was struck by something about your background, which is actually a little bit similar to mine, that you come from a medical family, you ended up in medicine. If you could sort of talk about that and talk about your dad, your mom, and why you ended up in vascular surgery.

Yeah, so it actually starts with my grandfather. He grew up in the coal mines in western Pennsylvania and went to medical school, and they rushed him through training to go to Korea for the war. He came back and decided to be a general surgeon. The story goes, and I’m not sure on the validity of this, but that he was part of some of the early antibiotic trials up in Milwaukee. He eventually moved out to California where he practiced for a long time. And my dad wanted to follow in his footsteps, but decided to go into cardiac surgery.

A nice easy profession there.

Exactly. I still haven’t quite figured out why he wanted to be a cardiac surgeon, but he says he used to paint the cardiac surgeons’ houses in California when he was a kid and he thought they were cool guys.

Anyhow, so I grew up in a medical family. My dad’s a heart surgeon and my mom was a nurse. And I tried really hard to maybe do something else with my life initially, just because I saw how hard—

Like what?

We talked about architecture, things that were similarly structural and creative, but I never got a bug anywhere other than medicine. I volunteered in my dad’s operating room restocking the ORs, and I loved that environment as a college student. It eventually got to the place where I realized that I wasn’t going to be happy unless I did something in medicine.

Tried to talk myself for a long time into gynecology. Again, I knew how hard my dad had worked to get through surgical residency and fellowship and how hard he continued to work as a surgeon.

GYN is, especially with those night deliveries. That’s not—

It was, but the thing that I struggled with, I just kept wanting everyone to deliver by C-section. I always just wanted to go to the operating room.

Yeah, as a third-generation surgeon, I learned some things from my grandfather and my dad, and part of it was always about doing your best and giving a hundred percent at all times. And then secondly, to never shy away from working hard. Work ethic was valued and work for the sake of work, that was a good thing. I had two great examples of physicians who really worked to become masters of their trade so that they could serve their patients and made sense for me to follow in that line.

My dad, I thought for a long time I was going to be a cardiac surgeon, and I’ll never forget the day I called to tell him I had chosen vascular. And before I ever told him. I said, “Hey Dad, what are you doing? What’d you do today?” And he said, “Oh, I sat in the corner and watched the cardiologist do a TAVR.”

Interesting.

And he said, “You really should think about getting some wire skills.” And I said, “About that—”

So TAVR is a transaortic vascular valve replacement, right?

Yep, exactly.

So it’s like percutaneous, catheter-based, just so there maybe some people listening who don’t know what that is.

Yeah. Which traditionally was very cardiology based. I think now the cardiac surgeons have been a little bit more involved in a lot of the procedures around the country, but my dad still—

It replaced a lot of valve replacements for stenosis, right?

Exactly. Yep.

It’s interesting, my dad was a radiologist as we had talked about, and actually my daughter is an interventionist, so I’m the middle. You’re the third generation, I was the second. The last thing I was going to do was going to be radiology and somehow circled back into the same sort of parental trajectory. But I’d say you’re a little different because you’re married to another physician and that presents a lot of challenges. You actually married the profession you almost went into, right?

Correct, yes. My husband’s a minimally invasive gynecologist. So yes, it does. Dual-physician households are— there’s a lot going on. We have four children.

That is a lot going on.

Yes, I had my first daughter, first child during research year of residency, and then my chief year I was blessed with twin boys. So started fellowship with twin two-month-old boys, and in my wisdom decided I wanted a fourth after my husband returned from deployment in Afghanistan.

How do you manage things like call and coverage and being exhausted and having to come home and still be— No one cares what you did all day, right? When you come home.

Correct.

You’re a mom and we need you. We need you to do stuff.

Yes. I think the first thing I’ll say is that I had a tremendous role model. And my father, he was either at work or he was with us. I remember vividly, he would show up to the baseball field in a suit after work. And he wasn’t on the golf course or doing other things; he was either at work or he was with us. And people used to say to me, “Oh, your dad’s a cardiac surgeon. You never saw him growing up.” And I said, “No, not exactly. He was very, very present.” And so he showed me that you can do it. It takes a lot of work and sacrifice and self-denial, but if it’s important enough to you, you make it work.

I’ll be the first to say that I married exceedingly well. My husband has been so tremendously supportive of my career. He has a lot more flexibility as a government employee. His hours are not like mine, he takes a lot less call. And so with the help—

We’ll make sure he hears that last segment of the podcast for sure.

Thank you. He knows, I try to tell him, I remind him regularly how grateful I am for him.

It does take a team.

Hundred percent.

I think that’s for anyone going into this, even if it’s one physician in the family, it’s a team effort, right?

A hundred percent. Everybody has their roles, but you have to pivot, and there’s some things that one of us are better at or not. Sometimes I’ve been on call for 48 hours and I’ll come home and he’ll be like, “I need you to deal with this child or this problem.” And—

Been there.

But my life is very, very full, but in a good way. At the end of the day, I go to bed exhausted knowing that I’ve given it all to my patients and my kids. I think hopefully things will slow down at some point once they get a little older, but for now, we’re making it work.

Yeah, I’m a little further along than you, and I’ll tell you, it stays busy, but busy in different ways.

Yeah, for sure.

It’s just a lot of fun. You’ve been sort of managing being a mom and a career. Let’s talk a little bit about, for the people who are out there kind of wondering: how do you start a career? How do you get your career rolling when you’ve got so many things going on? I know we’ve talked about that a little bit, but I think people would be really interested to hear how you went to your practice and really started building a clinical presence.

Yeah, I think to your first question, how do you begin to balance? I think the first thing is accepting that you never will have work-life balance. It will feel constantly out of whack, and there’s nothing you can do about that. Especially as a surgeon that’s dealing with a lot of call and emergencies and things like that, there’s just a lot of things I can’t control. And letting go of that I think is the first important piece.

The way you describe it though, you let it go when you have to let it go, but then you have other times when you’re pretty focused on your family, it sounds like.

For sure, yeah. We make it a point to take regular vacations. We go far away so that no one can find me or I don’t have cell service, and really prioritize that time together with our kids.

So in terms of your balancing that and then wanting to be, as you are, very successful in your clinical practice, let’s talk a little bit about that and what you’ve done to build your practice and some of the challenges you faced and overcame.

Yeah, so I’ve been at my current job for five years. I joined a very well-established practice in northern Virginia. So, the first thing that you, when you join a practice, is you try to find your place where, how can I help, how can I contribute? And I was hired to build up the aortic program. I graduated from Maryland, had a different set of complex endovascular skills that really hadn’t developed much here at our institution. And so in order to do that, I had to find the right people to build my team. Worked really closely with one of the cardiac surgeons here, well-respected, very senior, and then also with a senior interventional radiologist who had a lot to teach me. Starting my practice in the aortic space with the best and most-experienced people I could find at the hospital gave me a lot of backup and a lot of opportunity to learn.

Having a team, it’s been part of a team. Coming into something new and wanting to be part of a team and build a team, sounds like.

Yeah. And really in the OR too, because we had to start from scratch because our techs and our team didn’t know how to support these complex endovascular cases. And so we had to start from square one with wires, catheters, all that.

So how did that feel? When you’re in training, there’s always that person behind you that will be able to step in, but when you’re out there and everyone turning to you and saying, “Dr. Endicott, what do we do?” And you don’t have anyone else to turn to. How did that feel?

Yeah, it’s terrifying. I’ll say the best six months of your life are the last six months of training. You’re so confident that you can take on the world and then you transition out and all of a sudden it’s only you.

All the trainees out there should take note, right?

It takes about a year of sleepless nights before a procedure and worrying about ridiculous things afterwards, and then you kind of start to realize, “Okay, I might be all right at this. My outcomes are okay.” But it’s stressful, that transition is hard. It’s a necessary part of it.

True for all proceduralists, right? Probably in all forms of medicine, but even particular in procedures, because you sort have this memory of what the outcomes should be and kind of what you’re now on the line.

As you said, you had to sort of figure out where to fit in. Did you have any challenges about that? Did you feel sometimes people get sort of positioned into something where they don’t want to be the fit is maybe not exactly what they wanted? Just curious how that went for you.

I knew I wanted to do aortic surgery, and so in that vein, that assignment was a good fit. I’ll say I think the hardest part of transitioning, at least at our hospital system, and I’ve heard this from other women, is really earning the trust of your team up front. You know, when you’re new—and as a female with a predominantly female nursing teams—it takes a lot of effort, relationship building. I am naturally much more introverted than extroverted. And so just kind of going out of my way to build relationships, which I was a little resistant to at first, that goes a long way. Now my team will do anything for me. But in the beginning, earning their trust, it took some time.

I can say I’ve seen that. I haven’t maybe experienced it exactly the same way. But I can remember from my own time way, way back, being a general practitioner and a nurse coming up to me, very experienced and dealing with something in the ER saying, “So now what do you want to do, doctor?” So much of what we do is dependent on the people we work with. Right?

Yeah.

And you’re also associate program director for the surgery residency, is that correct?

Yeah, it’s one of the best parts of my job.

So why is that?

I love getting to see the trainees come in freshly out of medical school and grow over the course of five, six years. Just watching them succeed, struggle, overcome, it’s a pretty tremendous process and one that I find particularly life-giving for me as a mentor. They’ve come to be surgeons and they don’t know how to do that, and then over the course of five years, they slowly pick up pieces. And to get to give them feedback about that process, both good and bad, is fun.

Well, not many people will know how hard it is to be a program director right now. There are so many rules and so many safeguards. I was a surgical intern, so way back when, in a very hierarchical kind of program where feedback and any kind of concern for the intern didn’t exist. How do you do things now compared to your training? I mean, have you changed the way you interact with the residents based on experiences you had?

Yeah, I didn’t train that long ago, but it certainly is a different time in graduate medical education than it was even 10 years ago. It is hard to give feedback because the expectations of our interactions with trainees I think are different. It’s not okay anymore to holler and scream, and it never should have been. But I think the compliment sandwich goes a long way. And then also back to our previous conversation about building relationship, once the residents know that I care about them and I care about their development as a human being and a surgeon, feedback gets a lot easier, because then they don’t take it as, “Oh, she’s just mad at me.” They know that I’m giving feedback because I care.

Caring is the most important. And in our careers right now, I think many of us feel that there aren’t a lot of people that care about the physicians anymore.

(laughter) Yes.

So, sort of being able to project that to your residents I’m sure is really, really important.

You’re very active clinically, and one of the areas you’re active in is—I find fascinating—which is in dissections. And you’ve recently published on some work on, after hemiarch repairs, management of the flap with bare stents. So, what we’re talking about is, in aortic dissections when the walls of the aorta separate, it’s a critical issue and it’s coming right out of the heart, and it’s a little more of a management challenge as it goes further downstream. Can you talk a little bit about what your observations were and what you’ve been doing? And I might even ask you a few technical questions there.

Sure, of course. Dissections are, I think the best way to describe the management is, it’s a little bit of the wild west. There’s a lot we don’t know about how best to treat dissections. And a lot of it has to do with the heterogeneity of the disease and the interactions of pressure, flows, volume, aortopathy, the flap. There’s a lot we don’t know.

Your particular question, the vast majority of Type 1 aortic dissections are repaired with a hemiarch. In my institution, I have about 50:50 in terms of what the cardiac surgeon decides to do with these emergent cases proximally. And we found that there were times where the patient has clinical malperfusion, sometimes radiographic malperfusion, in the remaining dissection flap. And without a proximal landing zone, traditionally if you had a zone 2 arch or an FET, you would put a TEVAR in these and then treat with a bare stent, a dissection stent, distally to try to obviate the distal malperfusion. But as I said, with a hemiarch, there’s no proximal landing.

And so we published a case series of patients in which we took the dissection stent across the arch and landed in the Dacron, the “healthy” aorta, to see how we could get the rest of that aorta to remodel.

So essentially not having to worry about covering or putting the branch, the critical branch vessels.

Correct. So the open-cell stent—

By having this big open-cell stent, you can perfuse through that.

Exactly. And the idea is very similar to the recently available AMDS stent grafts in the US, except that it’s the bare metal stent goes in at a second operation. But the idea being that can we, upfront at the index hospitalization, really change the natural history of some of these dissections, particularly those that have a very compressed true lumen distally and malperfusion.

Looking at the study, the DART study I think it was, is that right?

Yeah.

And the results, the more proximally, the false lumen remodeled and even went away, and more distally, it’s more persistent. Do you think that’s due to all of the branches that are down there, all the intercostals, the esophageal, the bronchioles, and maybe some retrograde flow, or is it something about that part of the aorta?

Yeah, I think the farther you get down, you have more fenestrations and so more opportunity for re-entry into the false lumen. And that’s what we see clinically on follow-up scans. Typically, even if you don’t place any sort of bare stent, the top usually thromboses, and then you have with all the branch vessels, the persistent patent false lumen. But if you can get that aorta to stabilize in size, prevent the aneurysmal degeneration, you may obviate the need for more intervention down the line.

Now, there seems to be a trend to embolize the false lumen. Do you think that could be done in combination with the bare stents?

I don’t think so. I’d be worried about the coils kind of crossing over into the true lumen across the bare stents. I think the real question, and I teamed up with Dr. Luka Pocivavsek from University of Chicago, who’s also done a few cases where he’s put these bare metal— the stent grafts across the arch, the real question is what is happening? What are we changing? We’re not actually covering a fenestration, we’re just tenting it open or stabilizing it. And he’s been looking at some really elegant models trying to understand this process. It’s a lot of physics that I don’t think I ever understood. But really, again, just understanding what is happening here? Why is this stabilization working? How are we preventing false lumen pressurization by placing this stent?

And so I think probably the next step is really to understand what are we actually doing? And then we can say more definitively like, yes, this may or may not help someone.

Yeah, dissections are just so complicated. And they don’t come in a single flavor, everybody is probably a little different and the physics are just really very confusing. So a lot to learn. Probably as with many of the aortic diseases, it’s not a one-time treatment anyways, right? It’s sort of more of a chronic condition.

Correct, yeah. That’s what I tell all my patients, you have a chronic medical illness called an aortic dissection.

No, I think that’s so true. We’re probably getting close to time. Maybe just ask you, throw a question out there. So when people come to you and say, should I do vascular surgery, or particularly women come to you and say, what should I do this, what do you tell them?

So I tell them that I absolutely love my job, and I love being a parent and a wife, but that it wouldn’t be worth the sacrifices unless I absolutely loved what I do. And so I’ve always felt very called to medicine and to my patients and my trainees as well as to my home life. And so I think without that strong conviction in both places, it’s not worth it. But I’m very blessed to have both, and so my life will continue to be too full for the foreseeable future.

Well, better too full than too empty. And I think I agree with you completely, you’ve got to do medicine because you love it, and you love the patients and you love the problems. You almost have to feel that you would almost do it if you weren’t getting paid, but not quite.

Hundred percent.

All right. Well listen, thank you so much. Great conversation. Great to talk to you. I hope I run into you at one of the meetings.

For sure.

I really appreciate your willingness to come on the podcast.

Thanks for having me.