50 years of innovation: an enduring partnership with SIR

Episode Transcript

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

John, thank you for joining the podcast. Good to see you again.

Great to see you, Pete. Thanks for having me.

Yeah, maybe we should introduce ourselves for all of our millions of listeners out there who may not know us, but I’ll start. I’m Pete Yonkman, president of Cook, and unfortunately could now make it down to SIR, so I thought this would be a great opportunity to hear what’s happening live on the street from you, John.

Yeah, and I’m John Kaufman and chief medical officer and also interventional radiologist, so walking around the halls with two different hats on.

You’re the man on the street. We’re going to give you—we should give you the roving microphone and let you go out there and just interview people. That’s a good idea. We’ll do that next time.

We can try that.

Well, since I’m not there, just start off by telling me about the meeting. Are people attending, or is it a good meeting so far?

Yeah, so this is the 50th anniversary meeting, which is a huge event for us. The first meeting had, I think, 28 people in it, and they were all pretty established to senior radiologists who were doing angio. There’s a historical exhibit that we actually did a lot of support on, and fascinating to look at the agenda for the very first meeting. The first topic is a diagnostic topic. The second topic was called “Interventional Angiography and GI Bleeding.” So it was really fascinating to see that intervention has been, really, right from the beginning, a big part of what’s going on with the specialty and the society. So it’s 50 years; it’s the biggest turnout they’ve had since COVID, so a ton of energy, just a lot of people here. One of the exciting things is the number of young people who are here. There are even college students who are giving presentations, a lot of medical students, residents. I think that speaks to just the energy that’s still in this specialty, and the excitement around the specialty.

I think that’s terrific. That’s a terrific idea, because I think, from the meetings I’ve attended, after a while, it seems to be like you hear from the same people over and over again. No offense to you, John. I love hearing from you, but it’s great to have new voices in the mix, don’t you think?

Yeah, even I don’t like hearing from myself, so yeah, I love having new— hearing new voices, and I think a concerted effort both at the resident level and the faculty level to bring in new people, and that’s actually a challenge for me because when you’ve been around for a while, there are a lot of new faces. You’ve got to get out there, learn them, listen to them, learn those names, listen to them because there’s just a lot of new ideas and a lot of new information happening, and you can’t exist in your own little time bubble, so to speak.

Yeah, one of those kids is going to be the next John or Joan Kaufman along the way, right?

Exactly. Yeah, they’re all the future leaders, and sometimes they—I always tell the medical students that “you’re the most important people in the room because you have the greatest chance of really changing something in the future.”

Well, I know it’s only a few days in, but are you hearing any themes coming out of the meeting there? Are there certain topics that are kind of jumping out at you?

Yeah, there are several. I think on the kind of the device world, where we have a lot of interest; robotics, there’s just a lot of discussion about robotics, a lot of interest. Nothing is really commercial yet, but people are beginning to become very excited about the application of robotics at the IR procedures, whether they’re vascular or nonvascular. Still a ways to go, but much more than in the past. Ccancer remains a huge focus. There’s just always more in the cancer realm and the cancer intervention realm that we’re seeing in new devices.

The embolization world continues to grow. On the science side, I don’t think there’s a dramatic new procedure or idea for us, but what there is, is really development of a strong scientific basis or the beginning of that, or maybe we’re beyond beginning for what we do. One of the featured abstracts is on right atrial pressures after TIPS procedures, and how that can impact future outcomes. So we’re not just looking at patency stenosis. We’re really looking at the physiologic effects of what we do and trying to understand them. Of course, AI with the abstracts—invited abstracts from the residents—at least 50% of those involved AI in some way.

Oh wow, yeah.

Just whether it’s looking at tracking patients, scheduling kind of functions. There’s a very interesting AI abstract on a virtual expert who can do board preparation for oral exams.

Oh, wow.

Just a really kind of interesting concept. So AI is a huge part of this. I think that’s what you would expect—or hope for, at this point—just to see it involved here.

I want to ask you a question about that. You mentioned the robotics, so play that out for me 10, 20 years. Are we going to need IRs, do you think?

Is that a provocative question?

I’m curious what you think.

Yeah, so we’re going to need people, and we’re going to need experts in procedures. It’s hard to imagine a world in which you never need somebody who has some expertise. You may not need as many people to do certain procedures, so I think that it will impact how we do things, the number of people we need to do things. There are all sorts of scenarios of robotics that get very interesting when you think about them. You can have one operator potentially in the future sitting in one location, managing three or four cases at the same time, and at different points in the case—part of the robotic work is done, automated—it gets to a certain point where now you need a human to come in and manipulate the robot for that part of the procedure. Meanwhile, in another location and another patient, another robot is getting that patient up to the same point. And much the way it happens, actually, in real life in surgery, where a surgeon might have two or three rooms going and a team is opening in one room, the surgeon is doing the procedure in the second room, and the team is closing in the third room all kind of simultaneously, so you could actually, I think, have a robot do it. Will it put us out of business completely? I hope not. I don’t think so. My guess, there will always be— someone’s going to have to learn how to do a procedure and then teach the robot, right? So, hopefully not, but we’ll see.

Yeah, I asked that question because I think that’s a question that everybody’s asking about their own profession at this point. Between robotics and AI, everybody’s asking, How will that impact us? I think the way you describe it is a really good way of thinking about it. Just think about it from the simple terms, with our aging population across the globe, how are we going to create enough nurses, physicians, techs to be able to cover every single procedure that we need to? Can we take away some of the basic functions to allow our teams to use their best assets for the most important parts of the procedure, making sure that things go well? That’s kind of even the way we think about it in business, I think too. These are tools that are going to increase our efficiency and productivity for sure. It’ll change the way we do our work, but it’s not going to fundamentally replace humans, I don’t believe.

I think there’s going to have to be people alongside these. Now, we’ll use these tools differently. I suppose somebody in the 1900s would’ve had a hard time envisioning what we’re doing right now, you and I sitting in different cities, sitting face-to-face, talking about topics seamlessly, it’d be hard to understand. It doesn’t mean we don’t have to be there as humans; it just means we have a new way of doing things. So I’m very optimistic about robotics and AI. I think it’s going to make our outcomes better. I think it’s going to improve patient experience, but it ought to improve lives for all of us doing the work at the same time.

Yeah, I think there’s an aspect of all human interaction, but certainly in medicine, where empathy is an important part of the interaction—and just not the technical component. There’s the intellectual component. Am I making the right decision? Am I analyzing this data correctly? Coming up with the right diagnosis? But in the end, human to human, we have emotions. Reading those emotions, being empathetic, that, I think, is going to be a challenge for AI. Now, I may be wrong, because AI may be actually able to convince you that it cares for you and wants to listen to what you have to say, but I think that component is always—that human-to-human component I think is always going to be an important part of this.

Well, I think about our own stuff—where I live, Indiana—some of the more rural areas, right? They don’t have access to a John Kaufman. They don’t have access to care at that level. They may not have access to care at all, and so to be able to provide somebody like yourself or somebody well-trained to be able to do a procedure in a remote environment may really dramatically improve the amount of access we create for individuals in areas that just don’t have it. Not to mention some of the more distant areas of the globe that don’t have access to medicine. So I think it’ll—not only will it increase access to healthcare, it will improve the outcomes and it’ll allow us to do our jobs much better.

Well, there are many models. There’s the MI model, there’s the stroke model in the interventional world, maybe the pulmonary embolism model where we now have procedures that in the past were hard to imagine as being efficient, easy to protocolize, but you can, right? The tools are just getting better, like the pulmonary embolism world, we’re now treating daily across—not each institution, but—probably every day, hundreds of people are getting treated for pulmonary emboli who in the past just would’ve been put on anticoagulation and just told, “It’ll take you six months to feel better, and you might not ever get fully back.” Now it is a—

Yeah. Let’s talk—Oh, sorry. Go ahead.

Well, let’s just say it’s a routine thing, but you may not be able to have that in every hospital, right? So as the procedures mature, the tools to do the procedures mature, the protocols get more standardized, that’s a great opportunity for robots. We probably don’t need a robot to put a drain in, but these other things could be incredibly impactful to what you say, delivering care. So, sorry, I cut you off there. Sorry.

Well, no, you just mentioned something that kind of caught my attention, which was being able to either image or get to a place that we haven’t been able to get to before. That’s kind history of Cook. I mean, we started with a wire and a needle and a catheter for the Seldinger technique. But that quickly expanded to “What other part of the body can we get to now? How do we diagnose and how do we treat and how do we get there?” And all of that just kept expanding the amount of procedures and opportunities that were available from minimally invasive medicine.

I want to maybe get your thoughts on a project that we’re working on right now, which is called iMRI. It’s a partnership with Siemens, and that’s some of the things that I hear coming out of that, is that “boy, we can now image things that we couldn’t before.” It’s not just about reducing radiation, which is important; it’s about being able to enable these new procedures, and I find it interesting because we’re starting with a needle and a wire and a catheter in some ways, and exploring that area of interventional MRI. So I wanted to get your thoughts on that, and has that been a topic of conversation during your visit?

Yeah, it definitely has, and with, I think, growing excitement as people sort of begin to feel that maybe there is a successful future. iMRI has been around for a long time, I think that’s for exactly the reason that you described: Interventionalists look at the tools they have in their hand and say, “How can I use it and how I can try and do this?” So, people have been using MRI to try and do interventions for over 20 years.

I think this research collaboration has really put us in the position to make this a clinically valuable tool, and it is going to be an expansion of treatment opportunities, right? It’s going to be allowing us to treat things that we can’t really see well with any other modality. And that is almost always what you hear first: “Oh, iMRI, yeah, there’s all these things you can’t see, you can’t get to easily with CT or ultrasound, and wow, if you can do it in a multiplanar environment and MR, that will be great.” So I think it is very exciting. It is the expansion of the number of patients we can treat, but who knows what happens after that. It’s like the guide wire Seldinger technique, that someone will come up with an idea that hasn’t occurred to us in an application that may be just a grand slam for iMRI.

That’s what I’m excited about, is—I think interventional radiology in particular—it’s an area where, obviously, a lot of different disease states and procedures are covered. It’s also one where people are comfortable with their hands and trying new things and trying to push the boundaries, if you will, of where medicine is today, and so when we put a new tool like that in people’s hands, I think it’ll be fascinating to see where it goes.

Well, if you think of what we do with the tools we have now, right? I agree with you completely, and an example: I was having a discussion earlier today about genicular artery embolization of the knee and shoulder and other joints for pain. Who would ever have thought occluding arteries to a joint would end up alleviating pain? We’re still trying to understand why that works, but we know it does work. But here it is, taking existing tools and applying them in a way and being willing to do that, taking that kind of conceptual leap to do that. This is definitely not a specialty in which there’s only one way to do it and it’s always done this way and you’re going to do every case the same way. One of the beauties of IR is that we end up getting the problems that no one else can solve and they’re, “Can you figure out some way to deal with this?” and I think having iMRI in the toolkit is going to just open that up. It’ll be that idea of well, I’d love to do this if I can only see it. In some cases, this may make the difference between seeing and not seeing, but the radiation part, I think that is a big deal, you know, and I think as—of the old school, where—no one should ever do what I did—but if, sometimes you just didn’t wear your radiation badge, because if you thought it was going to be a long case, you didn’t want the dose to be recorded because it might mean you would have to stop working. How stupid is that? But that’s how people—you know, we did things. Much more focus on the potential issues for radiation, and it’s not—in pediatric patients, it’s definitely the patient, but—whether it’s a pediatric or adult patient, it’s the operator. And so if this is a way to minimize radiation, if this is a place where individuals who are pregnant want to do procedures and want to do it in a safe environment, they can potentially do it in this environment. I think that’s a bi, big help. When radiation goes away, lead goes away, and for some of us who have been wearing lead for a long time, and sometimes your back doesn’t feel so great at the end of the day, if there’s another way to do something where you don’t have to wear lead, that may also be a factor. So I think there are benefits to the patients and how we can do things for the patients, but also I think the operators may start seeing some advantages as well.

Yeah. I want to go back to the pain management side you talked about. So you mentioned shoulders. I’ve got a bad shoulder. Is that something that would help, block all the arteries in my shoulder joint and we down the pain, is that how it works?

Yeah, it depends. So, it depends on what’s going on with your shoulder. So now I’ll put the doctor hat on. So, if it’s an inflammatory process and a primarily inflammatory process, where even if it’s degenerative but primarily inflammatory, the embolization decreases the vascularity, particularly the area of inflammation, and for some reason, that decreases pain. If it’s something that’s torn or something that needs to be resurfaced, yeah, we’re not at that point; that procedure doesn’t sort of fit there. But what you’re asking is—points to something that’s a big theme here. And so just to tie back to the meeting. So that is just one way to treat a joint—and I’m by no means an expert in that—but what is very clear in this specialty and what you’re seeing here at the meeting is the idea of being a content expert, that you may have one way to treat something but you need to know how everyone else treats it and where you fit in and what the role of your particular procedure is. If you can’t offer everything, you need to really—to know where you fit in and collaborate and work with these other specialists to make sure that patients are getting the right thing. That is sometimes hard for physicians who like to do what they like to do, but that’s a really important part of this, and that’s one of the big themes here, has been for years, and it continues.

Yeah, you mentioned wanting to do what they like to do, and I’ve not been in the business as long as you have, but I think that’s changed in the 25 years I’ve been in the business. It feels like physicians have become much more collaborative to understand what is the best practice, what does the data show, less artistry, if that makes sense to you. I feel like that really is becoming more the norm. Do you agree with that?

Yeah, it is, and within interventional, it’s kind of an interesting issue because not everyone can do everything in interventional anymore. There are people that are very good at certain kind of procedures, maybe transvascular procedures, and may not be as good with ablations, and they need to know how to fit things in and collaborate with their colleagues as well as other specialists. I think one of the areas that has really brought that to light, particularly for IR, has been the cancer world.

The cancer world is a multidisciplinary approach to every patient. There’s very rare that patients come into that part of the medical system and don’t have multiple specialists involved in decision-making. Tt’s not that way particularly in some other specialties, so I would say there are definitely some other specialties that continue to feel like, “I’ve always done it this way, this is the way we do it, we’re going to continue to do it,” even if you potentially have another option. But that then rolls into how you bring forward and present yourself, how you interact, how you represent your specialty, where you publish your data in order to get a broader awareness. It may be an area where AI can help, right? If someone types into ChatGPT 4, “Is this a good procedure? What specialties deal with my particular problem?” Hopefully if IR is appropriate, it’ll pop up there along with vascular or GI or urology, anyone else.

You talk about students. Do you see them wanting to give IR? What’s attracting them to this specialty?

That is such an interesting question. So we just had our latest match—the match is the process where medical students put in their rank list of the programs they want to go to, and the programs do the same, and then a computer lines them up—and we had more programs in the match, more numbers or positions in the match than we’ve ever had before. Every single one of them or just every single, almost every one filled, and we had more applicants than we’ve ever had. So the popularity is going up. So we’re now 13 years into being our own specialty. The last fellowship ended in 2020, so the residency started in ’17, so we’re almost 10 years into the residency. So the popularity is going up. So, that’s a long way to give me time to think about an answer for your question. So why? I think it’s because the subject matter of the specialty is very diverse, so there is something here for almost everyone who has an interest in certain areas. We don’t do neuro, we don’t do the heart, we don’t do much with the skin, and we don’t do any psychotherapy. So if those are things that people want, IR is not going to be an area, but if you’re interested in a gastrointestinal, urinary, blood vessels, trauma, transplant, there’s just a huge range. Pain management, you mentioned—huge range. So I think, one, there’s a view that there’s just a lot of different things you can do, and that’s pretty interesting.

It is still just a really fun specialty. Doing procedures, procedural things are fun to do, and these are really fun to do. It’s rapidly evolving, so there’s a view that there’s going to be something new soon, and I think it’s viewed as a young specialty. It is not a very hierarchical specialty where things are dominated by a very senior group of individuals and it takes a long time. We’re a fast-moving specialty, and you can rise pretty quickly if you’re doing something really new and really good. You can rise pretty quickly within the specialty. So I think there’s that opportunity to make an impact that people see with our specialty. A lot of effort on getting more representation from women, getting a more diverse group of individuals because that’s where our patients are, right? So that’s also viewed as something that’s appealing to the specialty. So I think there are multiple reasons.

That’s great. That surprised me. I think there was a period there years ago where I thought there was some concern about that, and turned the other way.

Yeah, you’re remembering further back than I would like to remember, but right around between 2000, 2005, we were actually struggling to attract people through specialty, and I think one of the reasons for that was the fear that all the vascular procedures were going to disappear and go to vascular surgery. We’re still very much in the vascular game, and I think part of that has been because of the evolution into a clinical specialty where you’re seeing patients in the clinic, evaluating them, not waiting for someone to decide to consult you to do something for them.

Yeah, I’m going to take you back now a few years. Let’s say you’re going back and you’re just beginning your education. You’re thinking about where you want to do a fellowship residency. What area in IR, what part of the world today would you say, “I’m going to really focus on this to make my name”?

I think you’re asking me where there might be the most opportunity? Well, certainly part of the problem in answering that question, there are things I haven’t thought about that are probably a year from now going to become very current topics. I think—not to return to AI too much, but under an area or a group that’s really looking hard at this to see how this is going to impact the future of the specialty that’s not necessarily a procedural—particular procedure, particular organ. The liver continues to be a really interesting organ for us. We keep increasing our interventions in liver, whether it’s in the bile ducts or the portal vein, so becoming an expert on hepatobiliary, I think in the same way that individuals that become experts in oncology or in vascular disease, I think that’s a very interesting area that’s going to just continue to grow.

The pain management is, I think, a huge opportunity that IR is just beginning to understand. There are a lot of specialties that do that. Anesthesia, for example. So this would be to your earlier point, a multidisciplinary collaborative approach, but I think we’re really just beginning to understand what impact we can have with pain management. This is where iMRI may have a big role in visualizing targets that just have been hard to visualize. And then a combination of procedures and drugs is going to be very powerful. In the cancer world, doing procedures, embolizations, ablations to begin to trigger an immune response, and then adding an immunotherapy on top of that to get a totally different outcome than if you just did immunotherapy or you just did an ablation embolization, but understanding that we can actually bridge these therapies, so it’s not a drug-loaded device, but it’s combining systemic therapy with an intervention to then get actually a better result. And that may also play out in DVT and PE and other areas.

Yeah, I agree with you. I tell this to everybody. If I was just getting into business, I would make sure that I played with, understood, read about, watched anything involving AI at the moment. I’d want to know as much—that’s what I’m trying to do. I spend a heck of a lot of my time right now trying to—I didn’t come up in that world, so I’m not technical enough, but I really want to understand how it works and what it’s doing and how we can implement it and how we can use it, because it will come. In some form or format, AI will impact all of our lives, and so we might as well get used to it and figure out how to embrace it I think.

Yeah, for sure, and we just don’t know how it’s going to impact us, where that impact will be. Hopefully it’ll make us smarter in evaluating data. The potential for patient education with AI, or even being available, an avatar who’s available to a patient who has a question after a procedure. That could be huge. So it maybe have not a whole lot to do with actually the doing of the procedure, but the application to imaging, I think, has a huge potential. When we do procedures now, we’re very dependent on the basically being a radiologist, looking at something, analyzing it, and if you don’t see the break in the pattern, the difference in the pattern, what’s different, you might miss a finding. I think AI could really help, particularly in high-risk, rapidly moving situations where you need to make a quick diagnosis. That’s a whole ‘nother application for AI for the interventional world.

As I talked to you, it sounds like you’re having fun down there. This is where you like to be, right? You like to be in the middle of all of it—the science, the business, the medicine. I can see it in your face. It’s a good place for you.

Oh, well yeah, I’m having a ton of fun. I don’t want you to think I’m having too much fun.

No, I understand. You’d do it for free, right?

Yeah, no, it’s great. Yeah, I think if I can ask you a question? I’m at an interventional meeting, and we—Cook—have been going through a lot of processes over the last couple of years and have had to focus on certain other aspects of the business. I think people would love to hear what your thoughts on Cook’s role in IR going forward.

Yeah. Yes, I think that’s part of the reason of our presence there. I think hopefully people feel and see our presence within IR. It’s like you said, I think early on, like when we were involved in stent grafts and some of the peripheral {inaudible} procedures and there was that awful discussion about who should be doing procedures, and we just wanted to help support whoever was doing it. I feel like IR has really found their groove and has become the mainstay in a lot of the procedures that we are involved with.

And so I think if you talk to our team and what you’ll see is that, if you look at the pipeline, I think a lot of the pipelines are going to involve interventional radiology, a lot of those technologies and procedures. So I think it’s a very exciting area. I’ve always loved the inventiveness of IR. Other specialties are too, but I think IR, just by its nature sometimes, because need creates the opportunity for invention, so maybe some of those challenges that IR went through really became part of the DNA of “Hey, we’re going to branch out and try new things and make that part of who we are.” So I think it’s exciting. Like I say, I look at our pipeline; a lot of those things, we end up talking about IR in that, so now’s a good time, I think, for the specialty.

Yeah, one of the really fun things for me for being involved is seeing all the different places within the different parts of Cook where there can be cross-fertilization. So certainly because, probably from where I come from, IR’s always a big part of that discussion, but just a huge commitment going forward. It’s just an exciting place to be. It’s just continuing to grow.

Yeah. Well, I want to ask you—I know we’re on time here. That’s hard to believe. This is a great conversation with you, but how do you find balancing being the CMO and still being a practicing physician? You’ve done it for a few years now. Just curious, in terms of what you want to do with your life, how is it fitting in with your expectations?

Well, I would say through—everyone out there that if I had been smart enough to do this a couple of years earlier, I would be even happier than I am now. So it’s just been fantastic. I like having the flexibility and appreciate the flexibility to still be involved clinically. I think that just keeps you up to speed with some of the issues, and it’s being able to speak with some authenticity that you understand those problems, and not just with a tool, but patient follow-up, patient education, just that whole process. I feel just extremely fortunate to be part of Cook, which is, the culture of the organization is just so aligned with the culture that you have as a physician and how you approach your problems and how you prioritize the benefit of what you’re doing, and it’s not the benefit just for yourself. And that flexibility that you provide us to do that, it’s really incredible. It’s a lot of work. I’m glad there’s seven days in the week. That’s all I can say, but it’s been just a fantastic experience.

Yeah, was there anything that surprised you about, now that you’re sort of working with industry closely, anything that surprised you about that process, or misconceptions you may have had?

I would say two things that I found really a little different than I expected. One is how hard it is to bring a device forward. When people get frustrated, “Well, why can’t we have this? Why not? Why can’t you just change this and then it would be perfect?” How difficult that is. And the other part of that is how thoughtful our engineers are, our marketing people are, our regulatory people are in thinking through every little step. You know, a marker—not just how are we marking it, where is it, how big is it, what color, what that’s going to mean? I think it’s hard to understand how much goes into bringing a device forward, and I’m not even talking about the research, right? I have to say the quality of the people that I work with daily is phenomenal. The engineers, the research people, business people, marketing, educational groups, Studio 48, which—our production studio, which looks exactly like a major network studio—just incredible, right? And the team in there is phenomenal. So I think people would be surprised to know how deeply committed the people in industry are to what they’re doing and to the patients. Just as deeply committed as we are.

I agree with that completely. Before we wrap up, I do want to ask maybe one more question, which is, maybe say a few words about Joe Roberts. I know he’s at the meeting, at the 50th, down there.

Oh, yeah. It was just great to see Joe. Many of us with gray hair have known Joe for a long time. He’s been just a fixture at Cook. He is just an incredibly thoughtful, warm individual. No matter what you’re talking about, he’ll always kind of bring a very interesting angle to that and bring his own personal experience. It’s been just wonderful to see him, and I think he’s kind of been swarmed everywhere he goes.

Yeah, that’s great. He is one of those unique characters. Working with Joe is just always a pleasure. He brings a different energy and an attitude, and he’s just such a big personality in a lot of ways. Size, volume, intensity, just everything. He puts his whole heart and soul into everything he does, and you don’t meet many people like that along the way, and just really wanted to say thanks to him for all of his many years at Cook, but he contributed to interventional radiology in particular.

Yeah, no, I think Joe, he’s one of the icons, and it’s great that he’s here, and he was at the big gala, and he’ll be at the fellows dinner tonight, so I think he’s going to be swarmed again.

Yeah, well say hi to him for me.

Absolutely.

All right, well thanks, John. I appreciate your time on this. Go have some more fun out there. Don’t have too much fun—you know, I want you to earn your keep here, so act like you’re working hard.

Yes, sir. Okay, great to talk to you, Pete.

All right, thanks a lot.

All right, bye.