Bruce Perler, Julius H Jacobson II, professor of Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA, is the president of the Society for Vascular Surgery (SVS) 2015–2016. He told Vascular News that, on a professional level, “being elected president of the SVS was an incredibly proud moment”, and added, “There is no greater reward in any profession in my opinion than to be honoured and respected by one’s peers.” In this interview, he speaks about his early years in medicine, his plans for the SVS, his areas of research and his interests outside medicine including a passion for reading.
When did you decide you wanted a career in medicine? And why did you choose vascular surgery?
I decided at age four that I was going to be a doctor, and specifically a surgeon. I can remember vividly operating on my younger sister’s dolls: nothing too complicated, appendectomies, gall bladders, etc, during my childhood, and not without significant later punishment as I vaguely recall.
My initial plan during residency was to be a cardiac surgeon, and I actually accepted a cardiothoracic training position at the Cleveland Clinic, but I changed my mind and decided to go into vascular surgery one year later and withdrew and stayed on after my general surgery residency at the Massachusetts General Hospital for my vascular fellowship. The rest is history, and absolutely without any regrets! The appeal of vascular surgery, in part, was to be able to take care of the patient’s vascular system throughout the body. I never envisioned the evolution of the specialty to where it is today, but clearly there is no more exciting and vibrant specialty than vascular surgery, or a better time to be a vascular surgeon.
Who has inspired you in your career and what advice of theirs do you remember today?
My truck driver father and my mother never set foot in a college classroom, but I learned more from them than anything I ever learned in any school I ever attended in my life. They taught me three fundamental principles of life that I have never forgotten and that have guided my life and career honestly: always tell the truth and do the right thing, work hard, and be loyal to your friends and colleagues. As I have progressed in my career professionally I have always believed that one is not entitled to anything and all one can hope for is opportunity, and once you are offered an opportunity, it is up to you to seize the moment and make the most of it. My parents inspired me to be the best I could be.
Without question one of the most influential people in my surgical life was the late Dr David Sabiston, former chair of Surgery at Duke University School of Medicine. He was a towering figure in academic surgery who took an incredible level of interest in medical students and medical education. Not only did he train a generation of surgical leaders, but I have never encountered anyone who was more passionately committed to surgical education. One of his absolute rules is one should never use notes when presenting a patient. When a student would present to Dr Sabiston in front of the patient, he would turn to the patient and say “Mr Jones or Mrs Smith, isn’t remarkable how young Dr whoever here knows every important detail of your medical history and can recite them without the benefit of any notes,” and make a big deal out of it. In my career as an academic vascular surgeon, I have always been very compulsive in preparing my lectures and presentations, making sure everything was as well prepared as it could be. I believe that attention to detail emanated from my Sabiston education.
What have your proudest moments been?
The two proudest moments of my life were personal—the births of my son and daughter. While I am an imperfect soul and hardly have been a model dad, I am incredibly proud of the outstanding young man and woman they have become and love them more than they will ever know.
In high school I was not exactly one of the cool kids (as I am sure my friends and colleagues will understand). So I was completely shocked when on the superlative page of our senior yearbook (best looking, best personality, etc) I was listed “Most Respected” of the class of 732 graduating seniors. It is very humbling to be respected by one’s contemporaries.
In that regard and on a professional level, being elected president of the SVS was an incredibly proud moment. There is no greater reward in any profession in my opinion than to be honoured and respected by one’s peers. When I consider the incredible list of icons in our specialty who have held this position over the years, and when I think about the large number of dedicated and hard-working leaders in our society today who are truly deserving of this position, it is absolutely humbling to be singled out for the highest honour in our specialty.
How has vascular surgery evolved since you began your career?
The obvious answer to the question is the endovascular revolution. I lived through the era when some of our respected leaders felt that endovascular therapy was a passing fad and we should ignore it, and continue to do our open procedures. Thankfully, visionary leaders like Frank Veith saw the light, felt strongly that if we did not evolve we would become extinct, and led the way. I remember the SVS leadership struggling to develop the mechanisms for vascular surgeons to be trained in endovascular technique. I think one of the great success stories of our specialty, and of the SVS, is how quickly we developed those training paradigms and became not only endocompetent, but evolved to where now vascular surgeons are some of the pre-eminent leaders in the field. It is remarkable that over the last decade vascular surgery has assumed a leading market share in endovascular therapy. Now our challenge is to make sure that our young trainees are adequately trained to do open surgery.
Another important change, still in evolution, has been the increasing diversity in vascular surgery. Half of our medical students are women and we need to attract more women into our specialty. We are making good progress but have a long way to go.
What have your most memorable clinical cases been?
I have always believed that every one of my patients is a VIP, and my next case is the most important case I am ever going to do. That is how I would want a surgeon to treat a member of my family. Having said that, I have been at this for a few years so there are several particularly memorable cases for a variety of reasons.
As a first year faculty member right out of my training I remember a woman in her mid-80s who was transferred from her community hospital anuric with a solitary right kidney due to a previous left nephrectomy for malignancy, and with an occluded right renal artery. She had extensive comorbidity, including diabetes, severe hypertension, and end-stage coronary artery disease, and was in florid heart failure with extremely high pulmonary artery pressures. My Division Chief was unavailable so I got the case. She was admitted to our surgical intensive care unit and buffed up for several hours. Somewhat medically improved, she was still not a candidate for aortic clamping. I had recently read a paper by Libertino and Novick on hepato-renal bypass, but had never done one or even seen the procedure performed. Remember this is in the pre-YouTube era! The paper had very nice diagrams, it seemed like a great option for this patient, and I took her to the operating room and performed a hepato-renal bypass. It was my first and to my knowledge, the first hepato-renal bypass ever performed at Johns Hopkins Hospital. A classic case of see one, do one, teach one! She started making urine while we were closing, and left the hospital in a few days in good condition with normal renal function.
I also remember my first stent graft repair of a ruptured abdominal aortic aneurysm. The patient was an 84-year-old woman with a bad heart and bad lungs and the other usual comorbid conditions. I had published an outcomes study based on the Maryland state database, which documented a greater than 70% operative mortality after open ruptured abdominal aortic aneurysm repair among octogenarians, and this patient was at the bad end of the bell shaped curve in terms of her comorbidity. She survived that day and lived six more years of good quality existence thanks to the availability of endovascular aneurysm repair.
Oh, and there was that Friday when I performed an open pararenal abdominal aortic aneurysm repair on the mother of my Surgery chair. Not too much pressure on that one!
What would you like to achieve as president of the Society for Vascular Surgery 2015–2016?
My attention currently is focused on three areas. I am working with our executive director to develop a five-year budget for the SVS. Considering how small a specialty vascular surgery is, and our limited resources, what the SVS has accomplished since the merger a little more than a decade ago in multiple areas including government advocacy, defining high quality clinical care, publishing, education, and research support has been truly remarkable. However, the external environment is rapidly changing. Mergers and acquisitions in the medical device industry, the transition from print to electronic publishing, and other realities threaten the SVS revenue stream so that I believe that a course correction may be required and difficult decisions will have to be made about where we put our efforts and our resources. Our leadership team is also reaching to our major industry supporters to develop a mechanism of regular communication with them. I want our industry colleagues to know that we view them not as industry supporters but as our industry partners. I want to learn what they want from the SVS, and in particular our Annual Meeting. We can learn from them how to make our meeting as appealing as possible to our members and other practitioners to maximise our attendance.
Secondly, I am interested in focusing our public relations operation on branding the society to the lay public, including hospital and insurance company leaders. Over the recent past we have worked to brand the specialty and that will continue. However, I believe that we can do a better job in focusing public attention on the SVS, and in so doing on our specialty of vascular surgery. I believe the SVS can and should be more engaged in commenting on public interest issues that affect our patients and our practitioners, not just out of moral obligation but because I feel that in so doing we can get our name and what vascular surgeons do in the public domain. That is, I think we need to leverage the free media for our strategic interests. While this is a course change for the SVS, I believe it is a strategy we must pursue to advance our society and members’ interests.
Thirdly, I want the SVS to do a better job informing our membership about the broad spectrum of activities that the society is engaged in to serve the needs of our members, and in fact that the SVS is an indispensable ally in support of our members’ practices and so that potential members will conclude that SVS membership is worthwhile. I especially want to focus these efforts on our community practitioners who comprise two-thirds of our membership and who perform the majority of vascular surgery in the United States. The SVS, before the merger, was the “academic” society. I am afraid that brand has persisted in the minds of some. While we are engaged in academic activities for sure, we are much, much more today. The SVS is working 52 weeks a year to advance the interests of our members and we need to do a better job getting that message out. This is not your father’s SVS.
What challenges do you think still have to be overcome by interventional procedures in the vascular tree?
We have a way to go in developing the ideal devices that will satisfactorily configure to the curve of the arch as a long-term solution to the treatment of thoracic aortic or thoracoabdominal aortic disease. And, we will need to develop devices/materials to compensate for the confounding issue of the aorta as a living structure that may dilate or elongate over time. I do not see chimney and periscope grafts as a long-term solution to aneurysm disease. The future will clearly be fenestrated and branched grafts. I think continued improvements in imaging technology will parallel these advances.
What are your current areas of research?
For several years I have focused on outcomes research and have been interested in the influence of surgeon and hospital volume, and patient variables such as race and socioeconomic status, on the outcomes of major vascular surgical procedures. Within the context of the rapidly evolving healthcare system in the United States, I am interested in extending this work to assess the impact of our changing methods of reimbursement on outcomes and the ability to carry out cost effective care. In light of the relative aging of our surgical workforce, I am interested in looking at not only surgeon volume, but age and years in practice on outcomes.
What skills does the vascular surgeon of the 21st century need to develop?
In addition to having comprehensive clinical skills, and I firmly believe open surgical as well as sophisticated endovascular abilities, the vascular surgeon, and frankly most physicians in general, in the future will be well served to acquire business knowledge and expertise. Whether we want to admit it or not, healthcare is a business, and to date it is run by non-physicians. For example, of the roughly 6,500 hospitals in the United States, only 235 or less than 4% are run by physicians. Perhaps I am less than objective since I obtained an MBA, but I think it will be incredibly beneficial for our practitioners of the next generation to learn as much about the business side of the health care industry.
Outside of medicine, what are your interests?
While it may come as a surprise to some in light of my editorial activities, in my free time I love to read—especially biographies, legal thrillers, books about our politics, and action fiction writers like the great Tom Clancy books. It is a wonderful escape for me. I love warm weather vacations at the ocean. After a bit of a health issue a few years ago, I began jogging, and now jog upwards of 30 miles a week, although the athlete in our family, my daughter, points out that if I ran any slower I would be going backwards! As an alumnus of Duke University, one of my passions is Duke basketball and I have a couple of autographed pictures of coach Mike Krzyzewski on the walls of my office. He is a wonderful example for me of an effective leader: work hard, be a team player, play by the rules and good things will happen. Some would say that I am pretty out of control while watching Duke basketball games on TV, but these critics simply do not understand what it means to be a “Duke crazy.”
1972 AB Zoology, Summa cum laude; Phi Beta Kappa, Duke University, Durham, USA
1976 Doctor of Medicine, Duke University School of Medicine, Durham, USA
2004 Master of Business Administration, Johns Hopkins University, Baltimore, SA, Outstanding Student Award: Graduating Class
Postdoctoral training (selected)
1976–1977 Surgical Intern, Massachusetts General Hospital
1977–1981 Surgical Resident, Massachusetts General Hospital
1979 Chief resident, Pondville State Cancer Hospital
1981–1982 Clinical and Research Fellow in Vascular Surgery Massachusetts General Hospital
2000–2001 Leadership Development Program: Johns Hopkins Medicine
Academic appointments (selected)
2002– Julius H Jacobson II, professor of Surgery, The Johns Hopkins University School of Medicine
1997– Professor of Surgery, the JohnsHopkins University School of Medicine
1988–1997 Associate Professor of Surgery, the Johns Hopkins University School of Medicine
Hospital appointments (selected)
2013– Vice-Chair for Clinical Operations and Financial Affairs, Department of Surgery, Johns Hopkins Hospital
2002–2013 Chief, Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins Hospital
1998–2009 Founder & director, Vascular Surgery Fellowship, Johns Hopkins Hospital
1982– Director, Noninvasive Laboratory; Attending Vascular Surgeon, Johns Hopkins Hospital
1989–1991 Medical director-Intermediate Care Unit, Johns Hopkins Hospital
1982– Consultant in Vascular Surgery, Johns Hopkins Bayview Medical Center
1981–82 Assistant in Surgery, Massachusetts General Hospital, Boston, Massachusetts