Profile Robert Hobson

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Profile Robert Hobson

Vascular News talks to Dr Robert Hobson, UMDNJ-New Jersey Medical School, Newark, NJ, and lead investigator from the NIH/NINDS sponsored Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), about his beginnings in medicine, his early influences and the importance of the CREST trial.

When did you first decide you wanted a career in medicine?

I actually started becoming interested in medicine during my undergraduate studies when I did some voluntary hospital work and it evolved quickly thereafter to a passion for a career in Medicine. At that time I was looking forward to a career in the United States Army, but I enjoyed the academics of medicine.

What made you enter vascular surgery in particular as your first degree was in chemistry?

I always enjoyed and liked chemistry and it is one of the undergraduate degrees that, conveniently for me, feed from the specialty groups into medical school. At that time, I thought I might use the degree to become an industrial chemist but that quickly switched in my second year of undergraduate study to a Pre-Med status, in which I majored at Chemistry, at George Washington University.

You also did your postdoctoral training at army medical centers – how did this influence your understanding of vascular medicine?

I trained at Walter Reed Hospital and one of my major mentors who influenced me toward a career in academic vascular surgery was Dr Norman Rich. Formerly the Departmental Chair in Surgery at the Uniformed Services University of the Health Sciences, during my training in general and vascular surgery he was Chief of Vascular Surgery Services and Director of the Vascular Fellowship training program. Due to his influence, I became interested in the technical requirements of vascular surgery and its practice. What I liked about vascular surgery compared with cardiac was vascular surgeons supervised not only the operative event but also the diagnosis of vascular disease. It was a natural for me to apply for the fellowship because that’s what I really wanted to do.

Who were the greatest influences on your career?

Well, apart from Norman Rich, when I left the army and came to New Jersey I was greatly influenced by a gentleman named Benjamin Rush, who was Chairman of the Department of Surgery at New Jersey Medical School. He has a gentle but firm demeanor, was extremely supportive and willing to explore opportunities for vascular beyond general surgery. He stimulated me to establish the Fellowship in Vascular Surgery at the New Jersey Medical School and to strive for academic excellence. I worked with him for 15 years. Both Norman and Ben are still alive and good friends. I frequently see them at the American College of Surgeons or Vascular meetings, and it is reassuring, even to this day to be able to discuss items of mutual interest in surgery.

On a professional level what have been your proudest moments?

I think my proudest moments have come in the organization of major clinical trials involving carotid occlusive disease. I supervised the initial trial in the Veteran’s Administration on asymptomatic carotid stenosis and then over the last decade I have been working on the National Institutes of Health (NIH) sponsored Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). This trial is finally going to come to fruition; we have now randomized about 2,100 of the planned 2,500 patients. We have also completed the CREST Lead-In Registry, which was used to credential several hundred interventionalists at some centers in the US and Canada. It has been very fulfilling to know that group of committed clinicians and scientists involved in this evidence-based project. I am also tremendously proud of the Fellowship in Vascular Surgery at the New Jersey Medical School. We have dinner each year at the Annual Vascular meetings and meet with 25 prior fellows, all of whom are doing well in vascular surgery.

You are currently Principal Investigator of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), how important is the trial in the terms that it is NIH sponsored?

NIH-sponsored trials have the reputation of being most objective and they tend to carry some additional influence when compared to industry-sponsored trials with bodies such as the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS). While obtaining NIH funding is a formidable challenge, the resultant product is usually one which has great influence on practice patterns. For example, the North American Symptomatic Carotid Endarterectomy Trial (NASCET), the European Carotid Surgery Trial (ECST), the Asymptomatic Carotid Atherosclerotic Study (ACAS) or the Asymptomatic Carotid Surgery Trial (ACST) have all affected practice, because of their objectivity and funding sources. The randomized clinical trial emphasizes randomization of a homogenous population and as a result bias is reduced and results are used by practitioners. The trial also involves an extraordinarily competent Data Safety and Monitoring Board (DSMB) whose members are appointed by the NIH to oversee trial safety and results. For example, I have not been informed about results from the 2,100 patients randomized thus far and will not know until the code is broken when the sample of 2,500 patients has been enrolled. Whether results support carotid endarterectomy or stenting, or suggest no significant differences, it will have addressed an important question for clinicians and their patients on stroke prevention.

Do you think CREST will have a strong influence of the CMS regarding reimbursement for carotid artery stenting?

It should be quite influential because CMS called for and is awaiting the results from randomized clinical trials, including the current the CREST study, the Asymptomatic Carotid Trial (ACT -1) and the International Carotid Stenting Study (ICSS). CMS has wanted to analyze these data before expanding reimbursement for carotid stenting. They no longer are as interested in Registry data, which introduces an element of bias into the selection of the patient cohort. The magic of a randomized trial is not complicated; inclusion and exclusion criteria form its base to randomizations of a well-defined group of patients with the treatment of eligible patients in a prescribed fashion. Interestingly, CREST, ACT-1 and ICSS do not have medical treatment only groups. These trials compare the two procedures; stenting versus endarterectomy but do not include a medical therapy only group. The medical therapy used in NASCET and ACAS was confined to aspirin and management of blood pressure. We now have combined antiplatelet therapy (Aspirin and Plavix), statins, and increased public awareness of the importance of blood pressure regulation. So there are some proposals, some suggestions coming from CMS that ultimately they may want to see data in that area. However, expanded reimbursement should be based on the individual performance of stenting vs. endarterectomy. A separate group, the Trans Atlantic Carotid Trial (TACIT), is in the planning stage for a trial comparing the two procedures with the medical therapy only group. Final organization and funding of this trial are pending.

Outside of medicine what other interests do you have?

Over the years, my vocation and avocation have melded. So I have spent a lot of time on clinical as well as laboratory research in vascular surgery. I used to use my free time playing sports and particularly tennis, which I occasionally pursue now. I also love to spend time with a loving family. My wife and I like to travel together. I am lucky to have seen much of the world through my interests in Vascular Surgery. I was also a member of the United States Army Special Forces, which involved parachuting and all sorts of military and physical activities. But in the last 20 years or so as my participation has waned, I have become more involved in my love of vascular surgery. I am now more senior, so I may be too old anyway to be jumping out of airplanes!

Fact File

Robert Wayne Hobson II, M.D.

Education

1956–1959 The George Washington University, Washington,

      DC (BS (Chemistry))

Graduate and Professional

1959–1963 The George Washington University School of

      Medicine, Washington, DC (MD)

 

Internship and Residency

1963–1964 Internship, Tripler US Army General Hospital,

     Honolulu, Hawaii

1967–1971 Residency, General Surgery, Walter Reed Army

     Medical Center, Washington, DC

1972–1973 Fellowship, Vascular Surgery, Walter Reed Army

     Medical Center, Washington, DC

 

Military

1963–1975 US Army Medical Corps
1975–1995 US Army Medical Corps Reserve (Col.)

Appointments (selected)

1973–1975 Assistant Professor of Surgery
The George Washington University School of

      Medicine, Washington, DC

1975–1980 Associate Professor of Surgery

1980–1986 Professor of Surgery

1980–1986 Vice-Chairman and Director, General Surgery

      Residency, UMDNJ-NJMS, Newark, NJ

1986–1988 James Utley Professor and Chairman, Department

     of Surgery

1988 Visiting Adjunct Professor of Surgery

      Boston University School of Medicine, Boston, MA

1988–2007 Professor of Surgery

     UMDNJ-NJMS, Newark, NJ

1991–now Professor of Physiology and Associate Director,

    Program in Vascular Biology,

    Departments of Surgery and Physiology

    UMDNJ-NJMS

1995–2002 Director, NIH designated Center for Vascular

      Disease

     UMDNJ-NJMS (Academic Award in Vascular

     Disease)

2003–2007 Professor and Chairman, Department of Surgery,

      Seton Hall University School of Graduate Medical

      Education

2007–now Professor of Surgery, Mt. Sinai School of Medicine

Memberships (selected)

2001–2003 Advisory Council for Vascular Surgery

2004–now Chairman, Advisory Council for Vascular Surgery

1974–now American Association for Vascular Surgery, a

    Chapter of the International Society for

    Cardiovascular Surgery; merged with Society for

    Vascular Surgery (2003)

2000–2001 President

1975- The Society for Vascular Surgery

2006- Co-Chair, SVS – ABVS Ad Hoc Committee on

   Identifying Options for Independence

1988 American Venous Forum, Founding Member.

   President (1994-95)

1992- Association of Program Directors in Vascular

   Surgery, Founding Member

1998-2000 President

2004 Association of Chairs in Vascular Surgery

2004-06 Founding Member and President

1999- American Board of Vascular Surgery

2002-06 Vice Chairman

2006 Chairman

1999- The Society for Vascular Medicine and Biology,

   Fellow

2003-2007 International Society for Vascular Surgery (ISVS) –

    Vice President