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The 2022 Society of Interventional Radiology Annual Meeting Dotter Lecture: Mentorship

2022; Elsevier BV; Volume: 33; Issue: 11 Linguagem: Inglês

10.1016/j.jvir.2022.08.013

1535-7732

Riad Salem,

Radiology practices and education

I would like to thank President Johnson, incoming President Patel, Executive Director Hume, Society of Interventional Radiology (SIR) Foundation, and my SIR colleagues for the incredible honor of delivering the 2022 Dotter Lecture. Being mentioned in the same sentence as the father of our subspecialty is a distinction that represents the highlight of my career. This eponymous award is granted to senior interventionalists recognized for their contributions to the field. As a senior interventionalist, I have been fortunate to have led a rich and meaningful career developing new therapies, advancing standards of care, and helping bend the survival curve for tens of thousands of patients. For my address today, I selected a topic that I take extremely seriously, a philosophy, an approach, and a manner of comporting myself for 25 years. I want to talk about something that has been the most rewarding part of my career and provided me with the greatest professional satisfaction, opportunities for growth, and ability to help foster the next generation of interventional radiologists and other professionals. I want to talk about something I stumbled upon as a teenager and, since then, has been an essential part of my everyday philosophy. I want to talk about mentorship, on both professional and personal levels. Now, the dictionary defines "mentoring" as "guiding or advising to support personal growth." Unfortunately, I believe that this is far too narrow a definition, as it does not capture the essence of what I hope to share with you. Mentoring, the focus of this lecture and the lens through which I view this topic, I personally define as a long-term relationship among people on a joint quest to investigate, to inquire, to be intellectually curious, to advance ideas and concepts, and to embrace lifelong learning. However, integral to the relationship, in my mind, is that it is mostly about the mentee, not the mentor. In my opinion, the most successful mentors are those who embrace selflessness as the very essence of mentorship. Although I agree that there may be secondary benefits to the mentor, which I will address later, they are not the primary purpose of the relationship. For those of you who have observed, I tend to adhere to the principle that the most interesting lectures are those conveyed as stories. Mentorship, as a topic, is no different and best narrated through story telling. Here goes. My first experience with mentoring was at the age of 14 years. In Quebec City and in the summer of 1982, my parents, like any other immigrant family excessively pushing their kids academically, get fixated on the notion that I need to learn more about French literature: Moliere and Racine, the French equivalents of Chaucer or Shakespeare. They enrolled me in an advanced French course, apparently under the false impression that teenagers prefer French literature summer school over baseball or swim camp. They dropped me off and left me with a Quebec City family, admittedly not too excited about the upcoming 6 weeks. That evening, as I noticed students arriving from the United States, Korea, Japan, China, and Indonesia, all non-French speaking nations, it became abundantly clear that this is not an advanced literature school but a beginner course. The school headmaster, with his translator having no-showed, started to address the entire group in French. Witnessing this disaster before my eyes from the front row, I started to translate to those around me. Surprised to see me bilingual, he invited me to address the entire auditorium and translate his words in real time. From that moment, and for the entire summer, the headmaster promoted me to assistant headmaster. For the next 6 weeks, I became a mentor to hundreds of international students: to people twice my age. The student became the teacher. We studied vocabulary for hours daily and within 4–6 weeks, I witnessed people learn basic French. It was an experience I still remember vividly as if it was yesterday. I learned something that summer: I enjoy teaching, I enjoy mentoring, and it appeared to come naturally to me. I knew this would be in my future, and this is how stories about mentorship begin. In preparing for this lecture, I discovered that there was an entire spectrum of types of mentorship. One to be discouraged is the adversarial mentor or the antimentor. This is one in which selfishness, not selflessness, prevails. Although this may yield results in the long term, a pathologically dysfunctional relationship ensues. One example that comes to mind is that of Michael Debakey and Denton Cooley. Debakey and Cooley are legendary surgeons. Debakey was a cardiac surgeon, credited for developing standards of care such as coronary artery bypass graft, endarterectomy, the artificial heart, left ventricular assist devices, Mobile Army Surgical Hospital units, and the list goes on. He founded the Debakey Heart Center. Although Cooley was Debakey's mentee, they later had a falling out. Cooley ultimately went his own way and founded the Texas Heart Institute. By all accounts, he was an extremely skilled surgeon able to perform bloodless cardiac surgery. Medicine's most infamous and longest-lived feud stemmed from Cooley implanting the first artificial heart, illegally obtained from Debakey's research laboratory. Debakey labeled this as theft and morally reprehensible behavior. Cooley defended it as a desperate attempt at saving a life. Although this relationship lasted 40 years, both lamented after reaching a rapprochement that animosity, competition, and ill-will in an adversarial setting have no place in mentorship. Contrast that with another way of mentoring and collaborating, and what more relevant example than Dotter and Cook (Fig 1, courtesy Cook Medical). Charles Dotter met Bill Cook in 1963 in Chicago. Although Dotter had made his own prototypes, he needed Cook's business acumen to move them along. A great match from the start, they mentored each other. In LIFE magazine, Dotter was featured using devices Cook had made for him. A collaboration, a mentorship that forever changed medicine. What about Stan Cope and Bill Cook (Fig 2, courtesy Cook Medical)? I would like to spend a little more time on Stan Cope because this one is personal for me. Stan was a pioneering figure in interventional radiology (IR), responsible for many devices we use today: the cope mandril, the cope loop, needles, wires, fasteners, and the list goes on. Dr. Cope was the winner of the 2004 SIR leaders in innovation award, a distinction that I am humbled to share with him as the recipient 13 years later. I also had the privilege of being Stan's mentee while training at Penn. Figure 3 shows me with Stan, 25 years ago. Originally from France, he and I would banter back and forth "en Français," as I watched him perform amazing interventions. He taught me the lost art of bipedal lymphangiography (Fig 4), the cut down, imaging, patience, and temperament, as these procedures routinely lasted hours. I distinctly recall a moment at my first postfellowship job at University of Wisconsin (Madison) being requested to perform a thoracic duct embolization. After a good night's rest, I started the cut down at 8 am and completed the embolization at 10 pm: 14 hours of work! A moment of pride for young attending mentored by a legend. I recall that thoracic surgeon asking me the next morning with a perplexed look, "How did you avoid bowel and other critical structures with your needle?" Remembering I had asked Stan Cope the very same question a year earlier, I replied with the same smirk my mentor had proffered me "very carefully." The surgeon seemed satisfied and went on his way, thrilled with the clinical outcome.Figure 3Stan Cope and Riad Salem in 1997.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Riad Salem performing pedal lymphangiography.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The most endearing Stan Cope story I can share is circa in 1999, sitting in my apartment in Madison and receiving a call from Dr. Cope. He told me that he was biking from Minneapolis to Chicago through Madison and that he and Joe Roberts were fed up with the ride. They wanted me to provide food and a place to stay. I took them out to dinner and listened to their stories from their decades-long relationship. This Stan Cope story is illustrative of how these moments of interaction represent the ingredients of mentorship that can exert a lifetime of influence on you, and that unique expertise with thoracic duct embolization permitted me to help many patients over the last couple of decades. It also led to my very first publication (Fig 5). Imagine what being a co-author with Stan Cope does for a young interventional radiologist. Stan taught me to be slow, deliberate, and methodical with new ideas and concepts. These can take time to conceive and even more time to execute. Over my career, I have taken that advice to heart. Let us consider another example of positive bidirectional mentoring and collaboration. My wife loves Warren Buffett and Charlie Monger. As many of you know, they run a very successful holding company Berkshire Hathaway. For the last 15 years, she has attended the annual shareholder meeting on a father–daughter pilgrimage to what is known as the "Woodstock for capitalists." Buffett and Munger, together and during a mentoring relationship lasting >40 years, built Berkshire Hathaway into the eighth largest public company in the world. They got along so well that their partnership was set from their first meeting. Buffett learned a lot from Munger. One important lesson he learned relates to company acquisition, where he uttered "don't buy good companies with bad managers, you'll need to replace them…buy good companies with good managers and let them soar….and now you are freed up to pursue the next great acquisition." If you follow Berkshire Hathaway, that is exactly what they do. But Buffett's first mentor was Ben Graham, the father of value investing. As his mentor, Graham clearly shaped his career and investment philosophy. Buffett describes in his own words 3 main lessons he learned from Graham, and I quote the following: (a) do something foolish, and by that was not referencing a negative act, but one that has to do more with humility and a willingness to forgo self-importance; (b) do something creative, and by that he meant push the boundaries of the normal and think outside the box, and creativity is a muscle that should be used every day; and (c) do something generous. Buffett says of his mentor Graham this is where he succeeded beyond others, in expressing generosity of time, generosity of ideas. Now, think about how Graham's pearls of wisdom are relevant to us as interventionalists: humility, creativity, innovation, and generosity. Now, I would like to go back in time and share with you my first experience as a mentee, inspired by someone that started my path toward mentorship. David Davis (Fig 6) was my radiology chair in the 1990s. He had interviewed me for residency and apparently took a liking to me. After a successful first year, I made arguably one of the most outrageous requests a radiology resident could make. Feeling the need to maximize my time during residency, I walked into his office after building enough courage in June of R1 and asked whether I could go on a 4-month elective with Don Resnick to learn musculoskeletal radiology, a well-known program weakness for us, then upon my return complete a 1-year mini IR fellowship as an R2, and, as an R3/R4, be granted every Monday off from residency to complete a full-time MBA. He looked at me in disbelief and uttered "get the hell out of my office." With the door almost shut, he yells "I'll get back to you." Sure enough, 1 week later, he stops me in the hallway and says "Hey Canadian! That crazy proposal of yours is approved. Good luck to you." I share this story of mentorship because I will never forget the personal time he subsequently spent with me, supporting me and reassuring me, as I navigated arguably the most difficult 3 years of my academic life. Although the decision he made was not popular, he trusted me and he believed in me. From then on, an incredible lifelong mentoring relationship was born. I did go on to pass my boards and simultaneously complete a finance MBA as an R3/R4. He died in 2016 from Parkinson disease. He meant a lot to me, my first real mentor. I think of him often and hope he would be proud. God bless his soul! Now what was it about Davis that made him a great mentor? I would say 3 things. First, his ability to listen to what I had to say, to really listen: even when I could not verbalize my challenges given relative immaturity, he understood what I was trying to relay. Second was his ability not to impose explicit guidance but to help me perfect my thinking skills and yield a solution that worked for me. A true mentor's sine qua non is that they help reach a solution that best fits the mentee. Finally, he let me take risks. Encouraging risk taking within reason in an intellectually curious way, is an essential component of mentorship, and is the pathway to making a significant impact. Let us keep talking about types of mentoring relationships you can all relate to. Mentorship can be inspirational: think about someone you admire, someone you barely know, and someone you have never met and are unlikely to meet ever, and what it is about them you admire. You have now found inspirational mentorship. For me, on the more traditional side, I am inspired by my grandfather (Fig 7). He passed away when I was 5 years old. He was Chief Justice of the Syrian Supreme Court, and by all accounts, a man of supreme intellect, patience, fairness, and compassion. On the more eclectic side, I have been inspired by Tim Russert since my mid-20s. I never knew or met Mr. Russert. He was the host of Meet the Press. Tim Russert exuded professionalism and objectivity. I loved the way he comported himself and his ability to be neutral. He set a new standard in dialog with civility, the first to do so since Murrow and Cronkite. He also sparked my interest in politics. Mr. Russert suddenly died in 2008 and is missed every day. Mentorship can also be passive, observing and learning as someone executes their craft, and applying those lessons yourself. Personally, I have been passively mentored by Jordi Bruix, a hepatologist I hold in the utmost regard. He is a legend, unaware of the status he holds with me. Although he considers me a colleague, he is really a mentor. You watch someone like him, how they think and how they process information, and inevitably you develop a more advanced critical thinking process and become a better scientist, a better investigator, and a better clinician. This interaction recently resulted in co-authoring an important guidance document for liver cancer with global impact. Mentorship can be serendipitous and can influence you for decades. I think many of you might relate to this one. In 1997, as an IR fellow, I ended up at Joe's Stone Crabs at the ISET faculty dinner with the WHO'S WHO of IR. By pure chance, I got seated directly across a loud, commanding presence. This person was none other than the legend Barry Katzen. Here, I was enjoying dinner listening to Barry recount tall tales of IR. He interacted with me quite a bit, and that impression he made affected me for years. Unintentionally, Barry has been a mentor for decades. I have watched and learned from his approach to IR, his focus on program and practice development, and now, 25 years later, he even refers patients to me. Interacting with legends affects you for life. I was a no one. He was welcoming. He was kind. He made me feel like I belonged. Barry, I thank you. Finally, and maybe most importantly, mentorship can and should be reciprocal. Every day, I am surrounded by world class MDs who mentor me. For queries about oncology, who else other than Bobby? For complex portal hypertension and hepatobiliary, Bart and Ahsun; for impossible venous work, I will ask Kush; for crazy arterial cases, Resnick is my guy; for expertise spanning across all aspects of IR, I will ask Elias; for prostate artery embolization (PAE) and out of the box thinking, I will ask Sam; for ablation work no one else can take on, I will ask Kent; for his encyclopedic knowledge, I will go to Al; for her wisdom, I will seek out Mona; and finally, for everything else in categories not previously define, I will ask our section's ultimate mentor, 2003 Dotter lecturer and 2016 Gold medalist, Bob Vogelzang. I am fortunate to have colleagues at Northwestern who are at the top of their game, from whom I learn, who are quick to scrub in and help for any cases if needed. I distinctly recall a case in which Ahsun, Bobby, and Elias scrubbed in with me to help save a woman's liver transplant who required caval, biliary, arterial, and portal intervention all in the same setting. This is not a one off event but rather a way of life at Northwestern. As a result of this joint mentoring approach, our collective skill sets and problem-solving abilities get better, and patients benefit from this interaction. I would posit that we are all continuously improving as interventionalist because of this core philosophy at Northwestern. Mentorship of course is not something undertaken only on a professional level, it is also personal. My nephew Malek started living with me full-time as a 14-year-old teen without clear guidance or direction. With family support, some structure, direction, and hell of a lot of patience, l was fortunate enough to mentor Malek into the incredible young man he has become; from a high schooler who finally understood the importance of crushing SAT subject tests, to bonding over his first cigar, an engineering degree from Northwestern, and now a tremendous future ahead of him as an analyst for Riot games in Southern California. He is now bigger and stronger than I have ever been in every way. That opportunity to mentor him over 10 years, granted to me by his mother, my sister, is a life privilege I will never forget. Malek is here today, and he should know that I love him and am incredibly proud of him. My brother Acram was also a mentor (Fig 8). He went by Adam and I named my son after him. We lost him at the tender age of 50 years. As the impressionable younger brother, I watched and learned so many things from him, listening to Styx and Alan Parsons on vinyl, stealing Dad's Chevy for joy rides, and just watching how he behaved. He expressed many traits I hope to impart to my children: kindness, honesty, family, laughter, and sacrifice. These are things I think about with my brother, and his spirit helps guide me every day. The adage goes that death ends a life, not a relationship. I still have a strong relationship with my brother. God rest his soul! Dear colleagues, being a mentor is a significant responsibility. And mentorship is distinctly different from coaching, the former being about development and the latter about performance. However, despite that, I urge you to advance your own mentor–mentee relationships and be intentional in the way you go about it. During a TED talk, Patrick Boland beautifully relayed something I live by. He said "if someone supports you, gives you energy, loves you, accepts you, spend time with them. Invest in them. If someone is difficult to be around, sucks the life out of you, especially during challenging times, avoid them." The personal satisfaction derived from mentorship cannot be measured; it will define your legacy, because legacy is defined by consequential acts, not just cool technical tricks. If you do not have residents or fellows or students, mentor your nurses or your technicians. They will then teach their peers as they themselves take on mentorship roles, and the cycle will repeat itself. Mentorship is also not about you teaching others to become interventional radiologists. It is about working with people to unlock their inner potential and their inner drive and identifying what is best for them. Christine Menias spent her radiology elective with me in 1994. She tells me that our brief mentoring encounter sparked her interest in radiology. She is now editor-in-chief of RadioGraphics and a world-renowned body imager at Mayo clinic. Proudly, my mentees have also gone on to diverse career paths including law, dentistry, oncology, PhDs, engineering, patent holders and start up founders, and of course interventional radiologists. These are people I am now linked to forever. I continue to get updates from each of them, and in fact, in honor of this lecture, I received a very heartfelt note from Kevin Henseler, a mentee of mine >20 years ago. I was very touched by this gesture and thrilled that I was able to positively influence him. Mentorship is also not an activity reserved for those of us in the academic bubble. With few exceptions, an objective look at the state of the science as it relates to chronic limb ischemia, PAE, genicular artery embolization, illustrates the impact leaders in the private setting are having. Personally, for PAE and genicular artery embolization, I am mentored by people like Tiago, Francisco, Sonny, Ari, Sid, and Yuji. They are my mentors. To those colleagues in the nonacademic setting, your ability to be intellectually nimble and efficient is something we all learn from. You are pioneering different ways of providing interventional services, developing outpatient centers while running randomized trials, maintaining clinical excellence, and influencing guidelines. You are inspirational; you embody the innovative spirit of IR and serve as mentors to all of us. On behalf of all academicians in the bubble, I thank you! For those of you who know me, you know my mentorship style. Although we may playfully banter back and forth about silly topics of little consequence, at the heart of my interaction is a deep and sincere investment in you, to have you function at the highest level on the path of your choosing. To accomplish things deemed impossible by first breaking them down into a concatenated series of simple components, each with its own challenge. For me, this yields one of the greatest tangible joys of mentorship; seeing your mentee get a first-author article in JVIR, CVIR, Hepatology, JCO, or JAMA; seeing them win the Becker award, develop the nascent field of interventional endoscopy, taking IO to new heights, getting an RO1, bailing you out of a tough portal hypertension case, and teaching you about complex inferior vena cava flow dynamics. There is immeasurable pride derived from seeing your mentees' hard work be recognized by peers, and a similar amount of internal satisfaction in reflecting over the notion that as a mentor, you played a small role in catalyzing that journey. Moreover, pride is also derived from a career that generates a network scholar map that is dense in multidisciplinary collaboration (Fig 9). Now this is the Dotter lecture and at the end of the day, no one can compare themselves to him. But look, let's be honest, who in their right mind hasn't subconsciously tried to emulate him? Just a little bit? I am no different, but my approach to emulating Dotter, proudly, is quite subtle. You would need a very keen sense of observation to notice my very elusive attempts at imitating Dotter from these three totally random and spontaneously obtained photos. See if you can spot them from my recent faculty photo (Fig 10), or waiting patiently between cases (Fig 11), or doing a Y90 (Fig 12).Figure 11Emulating Dotter with cigarette in hand.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 12Emulating Dotter while performing Y90 treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT) I want to start closing by referencing Dotter again and highlight the spirit of mentorship and collaboration he embodied. I hope he is beaming with pride as he sees the specialty born from his hands focused on mentorship, comradery, and a collaborative approach to problem solving now innately part of its DNA. The stories I have shared with you underscore the important role mentors have played over several decades that allowed IR to contemporarily emerge as one of the most innovative and critically important in all of medicine. I hope you will agree with me that our continued focus on generational mentorship is essential for us to retain our status as the "swiss army knife" of medical specialties: versatile, high quality, and advancing therapies at a pace that eclipses other specialties. Now IR therapies are not the panacea, but they are omnirelevant to a wide ranging scope of medical afflictions. You cannot run a hospital or provide modern day health care services without IR. While I have been fortunate to have enjoyed a career rich in human interaction, exploring intellectual curiosity, the development of new global standards of care, I must say that one-on-one interactions with mentees and mentors have been by far the most meaningful. Yes, performing technically outstanding procedures that only interventionalists can do can only be described as remarkable in conception and almost implausible in execution and highlights the immediate impact of what we do. But mentorship is a higher order of service with a much more profound interaction, resulting in meaningful scientific advances. I ask leaders like all of you to adopt mentorship as a key tenet of your daily mission. I want to thank my parents, whose love and devotion permitted me to pursue all opportunities. They sacrificed everything for my success and begrudgingly, I am still their mentee. I also want to thank my wife Jennifer whom I adore. We have been blessed with 2 amazing children, Aya, who loves peppa pig, and Adam, who loves superheroes and most proudly, has agreed to be my newest mentee (Fig 13). To the rest of my family, my nieces, and my nephews, who flew to Boston to share this moment, I thank you! Your presence means everything to me. I hope to have inspired you today. I am a product of mentorship that has become a way of life, and my story is only but one example that highlights its importance, the impact it can have on you as a mentee, even if brief and ephemeral. Sic Parvis Magna: great things from small beginnings. I urge you to find your David Davis's and your Stan Copes, seek out opportunities for mentorship and, to an equal degree, let yourself be mentored, just as I have at Northwestern. It will positively affect your life in ways that are unimaginable. It will help our specialty continue to flourish in ways that are immeasurable and maintain its most innovative and paradigm altering status. I hope in years to come, you will message me, having heeded my advice, to share your story of successful mentor–mentee relationship. For those I have worked with, if I was ever fortunate to be your mentor but failed, please reach out and let me learn from my mistakes. If I was an active mentor to you even for a brief period, and many of you are in the audience, please know it was the honor of my life. Finally, if I have been an unintentional or passive mentor to you, when you are ready, look me up, I am glad to reclassify our relationship to "active" anytime. Just let me know, and let us get to work. I want to leave you with one final thought paraphrasing what I have heard Conan O'Brian say that is brilliant in its simplicity. He said "work hard, be kind and generous, and amazing things will happen." When it comes to mentorship, I could not agree with him more. Thank you for your attention, and thank you for the incredible honor of delivering the 2022 Dotter lecture!