BackTable Vascular & Interventional

In this episode, host Dr. Aaron Fritts interviews Dr. Marc Sapoval about practicing IR in France, the origins of the Global Embolization Oncology Symposium Technologies (GEST) Conference, and an upcoming conference in MSK embolization.The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/PX6J62---CHECK OUT OUR SPONSORSGlobal Embolization Oncology Symposium Technologies (GEST) Conferencehttps://thegestgroup.com/Laurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/RADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESFirst, Dr. Sapoval gives an overview of the French IR landscape. He outlines the training pathway, which is a four year radiology program with an additional two years of IR specialization. He also describes his role at an academic hospital. Dr. Sapoval says that in his country, collaboration with other endovascular specialists depends on both interpersonal relationships and business incentives.For the remainder of the interview, we talk about how GEST began and where it is today. In 2007, Drs. Marc Sapoval, Jafar Golzarian, and Ziv Haskal started the first GEST conference in Barcelona, after they realized the need for a specific meeting geared towards embolization. This inaugural meeting turned out to be a success, with attendance reaching much higher numbers than they had originally anticipated. Since then, GEST annual meetings have taken place throughout Europe and the United States. In recent years, it has found a permanent home in New York City.Dr. Sapoval introduces a new smaller conference series called GEST Hot Topics. An upcoming conference in this series focuses on MSK interventions, and it will be held in Paris on January 20-21, 2023. He emphasizes that it is an incredible opportunity to be part of a new field of IR. He highlights speakers who currently lead research efforts in MSK embolization and encourages all listeners to register and attend GEST Hot Topics: MSK Embolization.---RESOURCESGEST Hot Topic: MSK Embolization:https://thegestgroup.com/gest-msk-2023-paris/GEST Annual Conference 2023:https://annual.thegestgroup.com/GEST23/Public/mainhall.aspx

In this episode, Dr. Chris Beck interviews Interventional Radiologist Dr. Josh Kuban about his liver tumor ablation practice at MD Anderson Cancer Center, including how it's evolved over time with newer technologies. They also discuss patient workup for liver tumors, treatment with microwave ablation, and post-procedure follow up. Dr. Kuban shares why he uses microwave ablation technology, and the advantages of ablation confirmation software for these procedures.---CHECK OUT OUR SPONSORNeuWave Microwave Ablation Systemshttps://www.jnjmedtech.com/en-US/product-family/neuwave-microwave-ablation-systems---SHOW NOTESWe begin by discussing how Dr. Kuban started to get involved in interventional oncology and tumor ablation. He started off doing a broad base of vascular procedures. When he came to MD Anderson, he began building close relationships with oncologists which led him to become focused on ablation, primarily of liver and lung lesions.For liver tumors, Dr. Kuban primarily uses microwave ablation, while in the lung, he does cryoablation. The benefits of microwave ablation are the efficiency of the procedure compared to the time it takes to perform cryoablation. He generally does multiprobe ablations, which allows him to treat the tumor more aggressively from the beginning. He is able to do this confidently by taking advantage of ablation confirmation (AC) software. He always starts with a pre-procedure CT which he uploads to the AC software. He then compares his pre-image to his probe image which helps target the lesion intraoperatively. After ablating, he does another scan that has arterial and venous phases to look for bleeding. The AC software then takes the pre-scan and post-scan and merges them to show the ablation zone.Lastly, we discuss the impact that AC software has had on Dr. Kuban’s practice. When Dr. Kuban approaches a liver ablation case, his goal is to get the entire tumor in a single procedure, and he believes that he has to be able to see the margins in order to effectively ablate them. The software allows him to see the treatment effect in real time and provide more complete treatment the first time. After using this software, his recurrence rates have been very low, and he is confident that if a recurrence does happen, it is not due to incomplete ablation. He also emphasizes the effects that AC software has had on practice building. Because of this software, he is able to show images of cases to referring providers.---DISCLAIMERDr. Josh Kuban is presenting on behalf of Ethicon. The presentation reflects the opinions of the individual presenter, and the steps described may not encompass the complete steps of the procedure. Additionally, other surgeons may prefer different techniques, approaches, etc., as individual surgeon experience in his/her clinical practice, as well as patient needs, may dictate variation in procedure steps. Accordingly, results from any case studies reported in this presentation may not be predictive of results in other cases.Before using any medical device, review all labeling, including without limitation; the Instructions For Use (IFU), and relevant package inserts with particular attention to indications, contradindications, warnings and precautions, and steps for use of the device(s).Dr. Josh Kuban is compensated by and presenting on behalf of Ethicon and must present information in accordance with applicable regulatory requirements.The NeuWave™ Ablation System and Accessories are indicated for the ablation (coagulation) of soft tissue in percutaneous, open surgical and in conjunction with laparoscopic surgical settings, including the partial or complete ablation of non-resectable liver tumors. The NeuWave™ Microwave Ablation System and Accessories are not indicated for use in cardiac procedures. The system is designed for facility use and should only be used under the orders of a clinician.

In this episode, guest host Dr. Nicholas Fidelman interviews Dr. Michael Solen, a key player in the development and widespread adoption of transarterial chemoembolization (TACE). The doctors discuss how TACE became a major therapeutic option for liver tumors, his preferred method of TACE dosage and management, and exciting new frontiers in chemoembolization.---CHECK OUT OUR SPONSORVarian, a Siemens Healthineers companyhttps://www.varian.com/---SHOW NOTESDr. Soulen recalls his first ever TACE patient, who was a patient self-referring for a rare neuroendocrine tumor. As an IR fellow at the University of Pennsylvania, Dr. Soulen recognized the opportunity to incorporate clinic time into his IR practice. His push for clinical management of IR patients resulted in successful medical and financial outcomes, which also led his hospital to establishing an interventional oncology clinic. He emphasizes that a clinic presence is crucial to participating in tumor boards and being able to accept outside referrals.Next, we delve into the history of the CAM (cisplatin, adriamycin, mitomycin) conventional TACE cocktail, which Dr. Soulen developed alongside medical oncologists and pharmacists. These chemotherapeutics, combined with lipiodol and followed by particle embolics, make up the most widely used TACE protocol in the United States. Dr. Soulen reviews his preferred ratios and mixing method for maximal efficacy. He discusses his current RETNET trial that directly compares treatment of neuroendocrine tumors with conventional TACE versus bland embolization in terms of progression free survival, toxic side effects, and patient quality of life.Additionally, we address the high prevalence of post-embolization syndrome and SIR consensus guidelines for its management. Since chemoembolization is a highly emetogenic therapy, Dr. Soulen uses an oncology evidence-based combination of Benadryl, Zofran, and Decadron. He administers PRN pain medication on an individual patient basis. Furthermore, we discuss post-TACE management, specifically length of hospital stay. While all patients used to be admitted for overnight monitoring, this has shifted to mostly same-day discharges. This change has allowed the hospital to conserve resources and decrease costs.Finally, Dr. Soulen shares his perspective on new developments in interventional oncology. He highlights a need to identify TACE drugs that specifically target intratumoral hypoxic response mechanisms. He also compares transarterial radioembolization (TARE) to TACE, noting that the former has not shown superiority to systemic therapy in research trials. However, there are possibilities that TARE or TACE could be useful to slow tumor progression in radiation lobectomy or as immunostimulants for combination therapy with immune checkpoint inhibitors and CAR-T cell therapy.---RESOURCESRETNET Trial:https://clinicaltrials.gov/ct2/show/NCT02724540Transcatheter oily chemoembolization of hepatocellular carcinoma:https://pubmed.ncbi.nlm.nih.gov/2536946/Prospective Randomized Study of Doxorubicin-Eluting-Bead Embolization in the Treatment of Hepatocellular Carcinoma: Results of the PRECISION V Study:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816794/Randomised controlled trial of doxorubicin-eluting beads vs conventional chemoembolisation for hepatocellular carcinoma:https://pubmed.ncbi.nlm.nih.gov/24937669/Treatment of Liver Tumors with Lipiodol TACE: Technical Recommendations from Experts Opinion:https://pubmed.ncbi.nlm.nih.gov/26390875/Outpatient Transarterial Chemoembolization of Hepatocellular Carcinoma: Review of a Same-Day Discharge Strategy:https://pubmed.ncbi.nlm.nih.gov/29478795/Phase I Trial on Arterial Embolization with Hypoxia Activated Tirapazamine for Unresectable Hepatocellular Carcinoma:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139681/

In this episode, guest host Dr. Steven Raman interviews a founding father of percutaneous tumor ablation, Dr. Luigi Solbiati about the development of this revolutionary treatment, new therapies that have stemmed from it, and his vision for the future of interventional oncology.---CHECK OUT OUR SPONSORVarian, a Siemens Healthineers companyhttps://www.varian.com/---SHOW NOTESDr. Solbiati was a radiologist at the General Hospital of Busto Arsizio when he developed an interest in cancer in the 1980s. He traveled to the UK to learn about CT and ultrasound imaging. Upon his return to Italy, he combined this knowledge with his hospital’s department of pathology to obtain the first liver and abdominal ultrasound-guided biopsies for non-palpable lesions. Dr. Solbiati notes that in most of the world, ultrasound is personally performed by medical doctors, and it is an important skill to have.Next, we discover how Dr. Solbiati came to treat the first parathyroid adenoma using percutaneous ethanol injection. After Dr. Solbiati had performed a parathyroid tumor biopsy, the treatment team realized that her serum PTH levels had completely normalized due to compression of the overactive parenchyma. Inspired by this result, Dr. Solbiati researched past literature and saw the success of ethanol injection to cause sclerosis of liver and renal cysts. Since the patient was not a surgical candidate, she was willing to undergo ethanol injection, which was eventually successful. Dr. Solbiati explains that parathyroid tumors are hypervasculated and encapsulated, so they are able to contain ethanol and prevent diffusion. Additionally, the use of ultrasound made it possible for operators to visualize the amount of liquid ethanol entering a solid tumor.Overtime, Dr. Solbiati began to work with Dr. Tito Livraghi to inject ethanol and chemotherapeutics for hepatocellular carcinoma lesions. The outcomes from their initial studies are still used as benchmarks for locoregional therapies today. Their research gained publicity from scientific and non-scientific media, which came with both positive and negative reactions. Dr. Solbiati emphasizes the importance of collaboration with surgeons and other interventionalists to combine surgical, intravascular, and percutaneous therapies. Additionally, he also played a key role in the testing of cool-tip radiofrequency ablation.Dr. Solbiati highlights the significance of percutaneous ablation in advancing health equity. Ethanol and radiofrequency ablation are relatively cost-efficient and safe, which allows for higher quality of cancer treatment in resource-limited settings. He looks toward the future of interventional oncology as the “fourth pillar” of cancer care (in addition to medical, surgical, and radiation oncological treatments), the growing use of augmented reality for percutaneous procedures, and the increasing rate of combination therapy with immunologic agents.---RESOURCESPercutaneous ethanol injection of parathyroid tumors under US guidance: treatment for secondary hyperparathyroidism (Radiology, 1985):https://pubmed.ncbi.nlm.nih.gov/3889999/Hepatic metastases: percutaneous radio-frequency ablation with cooled-tip electrodes (RSNA, 1997):https://pubs.rsna.org/doi/10.1148/radiology.205.2.9356616

In this episode, guest host Dr. Sean Tutton interviews Dr. Bill Rilling and Dr. Sarah White about the history of the Society of Interventional Oncology (SIO), their current research and volunteer involvement, and future directions of the society.---CHECK OUT OUR SPONSORVarian, a Siemens Healthineers companyhttps://www.varian.com/---SHOW NOTESWe begin by discussing how the Society of Interventional Oncology (SIO) began. It started as the World Conference of Interventional Oncology (WCIO), but was formed into an official society with the goal to become the fourth pillar of oncology care, in addition to surgical oncology, medical oncology and radiation oncology. At the time of its inception, the group asked themselves whether interventional oncology would be bettered by the addition of a professional membership society, and there was a thoughtful and unified decision that it would be.Next, we discuss what goes into forming a society? When asking people to become members, pay money and give their time, they will expect some return on their investment. It's important to have a formal society, as it greatly advances the field forward. The ability to focus resources and effort completely on what you're passionate about is what having SIO allows. At SIO, we want people to be members of both SIR and SIO, it should be both, not one or the other.Finally, we talk about some of the current research funded by SIO. SIO fulfills the research aspect of the society by creating data, currently via the Ablation with Confirmation of Colorectal Liver Metastasis (ACCLAIM) Trial. This trial uses software to determine post-treatment margins in percutaneous microwave ablation for colorectal metastasis of the liver. With this trial, they hope to prove that this procedure results in high rates of clear margins, which will make it a minimally invasive alternative to surgical resection. Future research efforts will likely focus on coupling locoregional therapy with targeted immunotherapy. They aim to start treating new cancers, develop further partnerships with industry and pharma, and continue to produce quality data on response rates to promote interventional oncology as the well respected and accepted fourth pillar of oncology.---RESOURCESSIO:www.sio-central.orgACCLAIM Trial:www.sio-central.org/p/cm/ld/fid=809

In this back to the basics episode, Dr. Christopher Beck interviews Dr. Aaron Fritts about his standard procedure for nephrostomy tube placement, preferred tools, and troubleshooting tips.---CHECK OUT OUR SPONSORReflow Medicalhttps://www.reflowmedical.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/yEfEUY---SHOW NOTESDr. Fritts says that most of his referrals come from urology, and patients need treatment for hydronephrosis, kidney stones, and pre-operative access for lithotripsy. He goes over his workup, which can be expedited in emergency cases. He checks for normal coagulation tests and anticoagulation medications, since bleeding is the most common and dangerous complication of the procedure. Both doctors prefer to use CT imaging to map out the procedure, identify stone burden, and decide which calyx to access. It is important to use CT to make note of and avoid the colon (lateral) and paraspinal muscles (medial) when choosing an access site. Dr. Fritts also marks the access site before the patient gets prepped for the procedure, in order to ensure that the correct area is cleaned. Patients are usually under moderate sedation with versed and fentanyl.Then the doctors walk through a typical nephrostomy tube placement under ultrasound guidance. They emphasize that lidocaine needs to be injected all the way down to the cortex to maximize patient comfort and decrease the likelihood of patient movement during the procedure. Then, the needle is inserted into a calyx. While it is standard to access the lower pole to minimize bleeding risk, Dr. Beck sometimes prefers mid-pole access since this provides a shorter distance from skin to target and a more favorable angle to enter the ureter from the renal pelvis. The upper pole is generally avoided due to risk of diaphragmatic puncture, but it can be accessed if a stone is present there. Dr. Beck shares a tip about injecting saline to plump up the calyces and allow for better access.Dr. Fritts describes the two-stick technique that was primarily used before ultrasound access was available. He also recommends communicating with urologists in lithotripsy patients to identify optimal access sites for each patient’s lithotripsy. If the wire is placed directly on top of the stone and you have difficulty maneuvering the wire around the stone, you can inject saline to dilate the system and obtain a better angle for the wire.Finally, the doctors talk about drain selection, which is usually an 8Fr or 10Fr. The drain is secured with stitches, and possibly a bumper stitch. Pyonephrosis patients are usually kept inpatient, while other patients can get discharged after two hours. It is important to watch for hematuria and distinguish between mildly red venous blood from minor procedural trauma (which will subside) and bright red blood from arterial damage.---RESOURCESSIR Now:https://sirnow.sirweb.org/Ep. 97- Nephrostomy Tube Placement with Dr. David Feld:https://www.backtable.com/shows/vi/podcasts/97/nephrostomy-tube-placement-basic-to-advancedDiuretic agent and normal saline infusion technique for ultrasound-guided percutaneous nephrostomies in nondilated pelvicaliceal systems:https://pubmed.ncbi.nlm.nih.gov/22893420/Bumper Stitch for Drainage Tube Securement:https://www.jvir.org/article/S1051-0443(11)01353-4/pdf

In this episode, Dr. Aaron Fritts interviews Dr. Christopher Beck about gastrostomy tubes, including the evolution of his method, tips for patients who pull their tubes out, and why g-tubes are such a controversial topic in IR.---CHECK OUT OUR SPONSORLaurel Road for Doctorshttps://www.laurelroad.com/healthcare-banking/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/B9TbcW---SHOW NOTESWe begin by discussing indications and contraindications for gastrostomy tubes. Frequent indications are stroke patients, head and neck cancer patients, and trauma patients. Contraindications include uncorrectable coagulopathy, ascites, peritoneal carcinomatosis, or something interposed between the abdominal wall and the stomach, such as liver or bowel. Dr. Beck prefers having imaging to review, which most patients have. If no prior imaging is available, he will get a non-contrast CT abdomen the day of the procedure. He likes all his patients to drink barium for visualization of bowel during the procedure, but will not cancel the procedure if they didn’t drink it, as the insufflation should move bowel out of the way and there should be enough bowel gas to identify and avoid the bowel.Next, Dr. Beck reviews the details of his method. He likes to use monitored anesthesia care (MAC), because frequently he has patients with bad Mallampati scores. Additionally, anesthesia is very helpful with NG placement. Furthermore, it makes the procedure much more comfortable for the patient. He always checks liver margins with ultrasound prior to starting the procedure. He always gives 1 mg glucagon before insufflation and antibiotics per the SIR Guidelines App. As for equipment, he uses t-fasteners from Avanos, a dilator set, and a 20Fr G-tube. He used to start with 16Fr but found he frequently had to size up to a 20Fr. He uses a 24Fr peel away sheath. For the procedure, he insufflates, marks his entry point with a hemostat, and then numbs in all 3 spots where he will place his gastropexies. He uses 1/2 syringe of contrast for his gastropexy placement. He uses 2 t-tags, and prefers the C-arm in RAO rather than AP during this step. For G-tube placement, he aims 20 degrees toward the pylorus, and always makes sure he sees wire touching two walls of the stomach to ensure he is intraluminal. He uses sterile water to inflate the balloon rather than saline or contrast. Lastly, he always makes sure to get a good final image to confirm placement in the stomach.For post-care, on inpatients he rounds the next morning, checking that the tube flushes and then clears it for use. For outpatients, he recommends no feeding (via G or NG) for three hours and a consult with a dietician before discharge. After this, the patient can receive nutrition via NG. If the patient has no peritoneal signs, the G-tube can be used the next day. For tube management, he exchanges the tube every 6 months or sooner if there is an issue, such as the tube being pulled out or becoming clogged beyond the point of a bedside fix.---RESOURCESBackTable YouTube Gastrostomy Tube Demo:https://www.youtube.com/watch?v=17ep0AEkKqsEarly Initiation of Enteral Feeding:https://pubmed.ncbi.nlm.nih.gov/24674218/SIR Guidelines App:https://apps.apple.com/us/app/sir-guidelines/id1552455529

In this episode, Dr. Ally Baheti interviews interventional radiologist Dr. Judy Gichoya about her recent paper on artificial intelligence (AI) and the use of a deep learning model to recognize patients’ self-described racial identity, based on radiology images.---CHECK OUT OUR SPONSORSMedtronic Concertohttps://mobile.twitter.com/mdtvascularViz.aihttps://www.viz.ai/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/XIPsKR---SHOW NOTESDr. Gichoya had started by tackling the original problem of bias in diagnoses for chest X-rays, since it has always been difficult to tell whether something is a real diagnosis, or simply just a finding. Her team built a deep learning model; however, they saw that it did not work well for black patients. With further investigation, they discovered that their model had learned signals that correlated with self-identified race.Intrigued by this finding, Dr. Gichoya and her team sought to identify the factors that the model used when making its race determination. Because AI is black box in nature, the methods by which the algorithm learns remains largely unknown. When tested in other imaging modalities (mammogram, chest CT, spine imaging), the model still showed high accuracy. Additionally, the model retained accuracy when different information was eliminated from the images (ex. age, disease distributions, bone densities). The model was also able to predict race in healthy patients, showing that it did not rely on patterns of disease prevalence in specific ethnic groups.Next, we spoke about the implications of this research in developing risk scores. Deep learning models are able to look at factors that humans are not trained or able to see. Dr. Gichoya highlights the model’s potential effectiveness in predicting osteoarthritis risk in black patients. We also look at applications in opportunistic screening and information about social determinants of health. For example, most patients presenting with chest pain often get chest CTs. Dr. Gichoya thinks that these images can be used by the model to learn about patients’ environmental exposures, like pollution.We finish the episode with a discussion on the changing landscape of IR and how AI can be used as an assistive technology. Interventional cardiologists are already using AI to dictate their procedural reports in real-time. In the interventional oncology space, AI could help integrate imaging and pathology findings to determine personalized treatment courses. All of these applications depend on researchers’ ability to market their findings to peers and the public, Dr. Gichoya gives tips on how to do this.---RESOURCESAI recognition of patient race in medical imaging: a modelling study:https://www.thelancet.com/journals/landig/article/PIIS2589-7500(22)00063-2/fulltext

In this episode, Dr. Vishal Kumar interviews Dr. Mark Wilson, vice chair and professor of radiology and biomedical imaging at UCSF, and chief of diagnostic and interventional radiology at the Zuckerberg San Francisco General Hospital and Trauma Center about the evolution of trauma care in interventional radiology, translational research, and the impact of mentorship and student outreach.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/0RPqzN---SHOW NOTESWe begin by discussing how Dr. Wilson discovered radiology, and how he has come to be a leader in IR. He started out with an interest in psychiatry, and became involved in research on psychiatric brain imaging. As he delved deeper into biomedical imaging, his fascination grew. With help from his mentor, he began publishing, which motivated him to further pursue his passion for research. He learned about IR, and then got into UCSF for his radiology residency.Being at the frontier of innovations, Dr. Wilson has been involved in research on MR guided interventions, remote navigation, and percutaneous venous chemo filters. He says these projects have reinforced that radiology and research isn’t done in a vacuum. He depends on his collaborators in material science, chemistry, and other fields to successfully innovate. One thing he loves about the research lab is the student involvement, and getting to see high school and college students get their name on a paper. This is one area of student outreach that has an incredible impact and shapes future leaders in radiology and medicine.Finally, we discuss how Dr. Wilson spearheaded the role of radiology within the hospital infrastructure when they created the new SF General Hospital, the Zuckerberg San Francisco General Hospital and Trauma Center. He collaborated with hospital leadership and architects, as well as emergency medicine, surgery, anesthesia and nursing to build a state of the art trauma care center to serve the people of San Francisco. It fulfills its goal of bringing the services to the patient to deliver better and more efficient care. From CT scanners in the ED, to a hybrid trauma OR, this new center is one of the leading IR and trauma centers in the world.---RESOURCESThe History of the Zuckerberg San Francisco General Hospital and Trauma Center:https://zuckerbergsanfranciscogeneral.org/about-us/our-history/

In this episode, BackTable is on location in Barcelona for CIRSE 2022! Dr. Aaron Fritts conducts a live video interview with interventional radiologist Dr. Lorenzo Patrone. They discuss their experiences with balancing clinical, academic, and family responsibilities, as well as differences in the American and European physician work environments and the use of social media in medicine.---CHECK OUT OUR SPONSORSReflow Medicalhttps://www.reflowmedical.com/Medtronic Chocolate PTA Balloonhttps://www.medtronic.com/peripheral---SHOW NOTESDr. Patrone recounts his entry into the European IR speaking circuit. Through networking, he continues to meet speakers, learn from their experiences, and gain effective communication and presentation skills. He speaks about normalizing the feeling of imposter syndrome, especially when being invited to speak among IR founders and luminaries. He emphasizes personal growth and identifying where your passion and talent overlaps with lecture content.Dr. Patrone highlights the fact that the field of IR revolves around three different aspects: First, the pioneering phase to innovate new procedures, then the research/evidence phase to demonstrate reproducible results, and finally, the education phase to disseminate knowledge and inspire new generations of IRs. It is common for IRs to feel overwhelmed when trying to commit to all of these fields. Instead of trying to master all aspects of the job, Dr. Patrone recommends that clinicians find different angles of their jobs and hone in the aspects that make them enthusiastic to come to work. Personally, he prioritizes clinical care and teaching. We discuss how time is the ultimate luxury, and how to avoid over-commitment and burnout. We also consider societal gender roles and talk about unjust extra pressures faced by female physicians.Then, we look at some key differences between a physician career in the US, versus one in Europe. Dr. Patrone comments on the pay gap, training pathway, and overall philosophy of the Italian and British healthcare systems.Finally, we discuss benefits and misuses of social media within the medical community. Dr. Patrone emphasizes that social media should be used as a tool to teach and inspire, rather than a platform to criticize individuals or specialties. Regarding case-based posts and feedback, he highlights the point that every clinician could have a different but valid approach to each case, based on the practice setting and operator skill. He also encourages other posters to talk about case complications, which can provide enormous educational value for learners.