Episode 85: Building credibility and goodwill in hospital leadership with James B. Spies, MD, MPH, FSIR

The following transcript was generated with AI. There may be errors or typos.

Moaz Choudhary, MD: So, welcome to the podcast, everybody. My name is Moaz Choudhary, and I am your host for today's episode.

Today's episode is a special one, not just because we have with us somebody who is a true leader in interventional radiology with an impact that extends across patient care, research, and national leadership, but also somebody I deeply regard as a mentor, having had the pleasure of training under him, and somebody I personally look up to as a role model.

In today's conversation, we'll reflect on his journey, how leadership has evolved, and lessons that are particularly valuable for early and mid-career physicians.

Without further ado, I'd like to introduce Dr. Spies, who's currently a professor and chairman of radiology at Georgetown University School of Medicine. He's a past president of SIR, and has also received a gold medal from the Society of Interventional Radiology.

So, thank you, and welcome, Dr. Spies.

James B. Spies, MD, MPH, FSIR: Well, thanks, Moz. It's great to be here, and great to speak with you again.

Moaz Choudhary, MD: You know when people think of you, you're regarded as one of the true giants in interventional radiology. And I know your contributions really need no introduction, but I believe it's always valuable to understand the journey behind the impact.

So, could you share with us how your path in medicine and interventional radiology began, and what shaped your career early on?

James B. Spies, MD, MPH, FSIR: Well, first, you know, when someone calls me a giant of anything, it makes me, you know, it's a little bit embarrassing. I think of the giants of intervention radiology as those that taught me. Ernie Ring, and just the whole generation that Eric Martin and that generation started and opened the, the SIR to general membership. I was one of the early general members way back in 1998 or 1999, I think.

So, I'm the only physician in my family ever, and I just kind of got excited about medicine during a physiology class in high school, so without really thinking about it longer than about 20 minutes, I decided I was going to be a doctor, and sort of just directed my energies in that direction.

And it is interesting, I think, for students in general, you make a decision, and you often don't, you know, raise your head back up and think it through again, you just keep going, because getting through medicine and medical school and residency, etc., is one step after the other. So, anyway, I went to Georgetown Medical School. I did training at UC San Francisco, residency, and then I did a fellowship at NYU with Bob Rosen, which was really fabulous.

And in order to pay for medical school, I was on an Air Force scholarship, which in those days was very, very common to have a military scholarship. And my medical school class at Georgetown, I think about 60 or 65% of the class was on a military scholarship. So we all had to go back and pay our time back, which is one of the great, positive things that occurred in my career.

So, the first thing that happened to me was that I got out of fellowship, and I went to their large medical center down in San Antonio, Texas, and we had a full interventional practice, we had a residency with 32 residents, we had a fellowship in interventional radiology, and I was able to slide right in.

And in the military, it's interesting, you get leadership opportunities very early. I actually became the chief of Interventional Radiology my second year because the guy who had been chief rotated off, he'd finished his commitment, and moved on.

So, getting into SIR leadership roles, I will say, I can remember distinctly how that happened to me. I was at Wolford Hall. We used to have this program there with Brook Army Medical Center across town and with UT San Antonio, that we would rotate speakers, so they would come down, and we'd have a speaker that would go to all three places and essentially give the same lecture. This, of course, was in the days before Zoom. And Arena von Breda came, and Arena, at the time, was on the Executive Council of the SIR. I don't think she had become the president, and she was the first female president of the SIR.

And so she spent a day with us, and we kind of showed her cases, and went out to lunch, etc. And along the way, she kind of looks like  she looked at me, and she says, you know, you look like you might have some energy. Do you want to be on a committee?

The first thing I would say is, to anybody out there, is when somebody asks you if you want to be on a committee, the first thing out of your mouth should be, yes, sure, I'll do that.

I didn't even know what the committee was. I mean, it was the Standards of Practice Committee. And, for the SIR I got on the committee. Mike Pentecost at the time was the chairman of the committee, and I was on it for a few years, through the end of my, Air Force time, and then Mike moved up on into the council, and then I became the chair of the Standards of Practice Committee really very early, like in 1991, I think, or somewhere around there.

I was the chair for several years, probably 5 years or so, and anybody who's been on the committee knows that it's a lot of work. There's a lot of paper, there's a lot of writing stuff, there's a lot of conference calls.

Going over, you know, line-by-line documents, etc. And then I moved up to the council back in the mid-90s and went through that. And so, that path, which to many young people today would seem to be, oh my gosh, that's impossible. How could you possibly, you know, go from that to being on the SIR Executive Council?

It is really If someone asks you to volunteer, you agree, and then you do the job. I mean, that's the key thing. You know, I wasn't a big leader, I had, I think, 8 people or something on the committee, but we basically did a lot of work, and we put out a lot of the very early SIR standards. And what people want is when you get asked, well, we'd like a standard NX, they'd like you to be able to finish that. And we were able to do that.

So the first thing is, be a good volunteer if you're gonna volunteer, and be engaged. To be honest with you, I never really had aspirations to be a leader, per se. It was more like, I'd like to contribute. I'd like to do something that moves the field forward. And also, I would say that volunteering or doing activities outside your regular clinical work really kind of broadens your horizons. It diversifies what you concentrate on, spend your time on, and it's an education by itself.

So, I think that there's a great personal benefit to volunteering for committees, because you get to put a lot of your energy into something other than just another case and one case after the other.

So, that was sort of how I got started in it, and it really was enormously rewarding. There's just no question about it. The best thing that ever happened to me was saying yes to being on my first committee.

Moaz Choudhary, MD: Definitely, and at this point in time we are very lucky where all these things are streamlined, and I think the SIR volunteers and the SIR Connect do a great job of highlighting and sharing opportunities when they exist. But it s great to hear that's where your leadership role and everything started.

So, and that actually answers the next question I was going to ask you, is, leadership advice and all, so I'm glad you touched on all of these.

James B. Spies, MD, MPH, FSIR: Well, so, there are two kinds of leadership, obviously. There's leadership in an organization that you volunteer for, and that is one side of you, and it's an important side, obviously for you. You know, you've done a lot of volunteer work with the SIR and others.

It's also important that in your day-to-day life, you demonstrate the characteristics that would have people think of you as a potential leader, and they're really very simple. I mean, they're the simplest things in the world.

The first is that if you have a job, and particularly if somebody's paying you to do the job, you do the job. And you keep the complaints to a minimum. You basically look for ways to solve problems on your own, you put in the effort, and you accomplish something, whether that is establishing some new line of something, or it's just getting through the day's cases. Getting through the day's cases without creating chaos, or without creating a lot of unhappy people because you're in a foul mood.

Those things are not positive leadership qualities. You have to have good attitude, hard work.

The second thing about leadership in your day-to-day practice is that people have to recognize that you are a good person. And by that, I mean that you are honest.

When people ask you things, you tell them the truth. You never dodge things, you never shade the truth, you never do anything that would lead them to not fully trust you. Also, you have to do the right thing. You have to do what's best in medicine, particularly what's best for patients, even when that's something that you don't actually want to do. You know, that case in the middle of the night went, well, I could wait until tomorrow morning, but then you realize that it might be better for me just to get up and go in and evaluate this patient and get it done tonight. And that's because you can't ever quite know what could happen if you don't do that? The patient deserves the best that you can get. So, you have to be dedicated to doing the right thing, you have to be honest in your day-to-day practice, and then once you get some leadership opportunities, for example, as a section chief, or a program director, or whatever that might be.

The other key thing is that you have to be fair. People have to view you as being a completely fair person in the way you approach things, because if you seem to be biased in one direction or another, either towards an individual, or a group of individuals, or your side versus the other side, and you lose sight of what's really right in the world, then you're going to kind of get off track.

And if you just display those characteristics, people will naturally be attracted to having you work with them, and so they give you chances to do things. Your hospital, in your medical group, you know, in the SIR.

Moaz Choudhary, MD: Yeah, that's well said. I think being fair is not easy. It has some backlash, but I 100% agree. I think that's the most important thing. So

Along the same lines, I know you've lived in the world of diagnostic radiology and interventional radiology, and you talk about fairness with colleagues. What do you think are, apart from that, are most common pitfalls that IR leaders fall into when trying to balance or leading a department where they also have DR colleagues, and vice versa?

James B. Spies, MD, MPH, FSIR: So, well, there are two things. One is, what are the pitfalls for an IR chair in a general radiology department, you know, and that I think I'm in my 22nd year or 21st year of being the chair of the radiology department here.

Fairness is the key thing, particularly when you have different sections. So, I'm a leader of a diverse group of people, I think we have 48 faculty members, and everyone wants something. Now, it isn't like they're in your office wanting something all the time, but in general, they want something from their leaders. Sort of the most basic thing they want is they want to have a work environment that they feel respected, that they enjoy, that they work with people that have the same sort of general goals in terms of patient care and providing service and having an exciting practice. And they want to be in an environment which they can transparently see that they are being treated fairly.

So, you know, I've been fortunate in that I've been able to evolve our practice early on, and then later when we merge into our larger, sort of, mega group that we have now, that we have completely transparent compensation, for example.

So, nobody gets any special deal, no one gets paid extra than the other person, nobody can come into my office and pound on the desk and say they want more money. I mean, they can do it, I mean, they have done it, and I've had to gently decline, saying, well, that wouldn't be fair. And those are almost always the first words out of my mouth is, yeah, I'd like to do that for you. But, you know, that wouldn't be fair.

And so then you try to come up with solutions that you can apply to the entire group that would improve everyone's life in some measurable way. So that's that part of it, which is, you know, how do you apply fairness in that setting?

As IR leaders, trying to actually advocate for what you want—I would say the biggest pitfall I've seen in IR leaders—And this, I think, has to do with our—maybe this is a complete stereotype, but our personality type.

You know, we often think of ourselves as a sort of a different species than diagnostic radiologists, that we are tend to be doers, we tend to be more surgical on our thinking, we tend to be more aggressive, and many IRs' personalities are like that, and a lot of the positive feedback we get from the things we do are the sort of new and exciting and a little bit daring things that we do in practice, that solve some clinical problem or whatever.

But they take that kind of that aggressiveness or directness, and they take it into an environment in which the other people in the room don't have that personality type.

So, this really comes down to reading the room, you know, understanding the room, understanding the people that you're talking to. I've gone through all these things. We wanted to start a clinic back in, like, 1997, shortly after I got to Georgetown. And you can think of all the 9 reasons why you have to have one and all that, and it's a very sound argument, and you think anybody in their right mind would see that you need this, and they would just obviously automatically agree. Well, the person on the other side of the table may be the, you know, the chief financial officer, is thinking that he doesn't really want to invest $250,000 into a build-out of office space for you. Or it may be another service that is also looking for space, and you're vying against them. And you think that you're more deserving, but it turns out that, for varying reasons, they may have a greater space crunch than you do, or whatever.

So, you have to understand the context of what you're asking for. Understand what the person that has the power to give you what you want. You need to understand what they need. So, if what they need is greater clinical volume, you can say, by having this clinic, I think we're going to be able to expand our volume by X amount, and we're going to be able to get away from the inpatient and small outpatient procedures into more complicated things, you know, the liver interventions and, you know, the interventional oncology and UAE and all those other kinds of things, and we are going to be able to bring a new population of patients into the hospital. Now, of course, they're going to want to see a business plan and some projections of numbers, etc. But really, what they're looking for is, how can they solve their own problem? And if you're in their office asking them for some limited resources, but that will help them solve their problem in the longer run, then they're more likely to be on your side.

Moaz Choudhary, MD: No, that's well said. I 100% agree, and I think as more and more IR people expand, this is the model they're following, IR clinic, and then coming up with that. But having said that, you've also spoken about communicating with institutional leadership.

Any words of advice on how to navigate different personalities, and how do you maintain credibility while still advocating for your division and your people?

James B. Spies, MD, MPH, FSIR: Well, when you advocate, you have to have a solid positive argument for why you want whatever it is you're advocating for.

So, I'll give you an anecdote. For many years, we had what's called a capital request committee here at my institution. And they had 3 or 4 chairs in there, and they had the chief of nursing, and they had, like, the chief of biomedical, and a whole range of different people from across the hospital. And the millions of dollars they had every year that were designated to be doled out by the hospital leadership.

This group of people made the priority list. And so I sat on this committee because we were a major user of capital investments, you know, I mean, basically, radiology, you know, radiology chairs, all they want is more new equipment, replacement equipment, you know, every year something different. So, and they had a lot of, you know, oncology was there, or radiation oncology was there, etc. Well, there was one guy, and I'm not going to name his service, but every single thing he asked for was an absolute crisis, and it was just, “Patients are going to die if we don't get this.” And, you know, he just was almost, shrill in his advocacy for what he wanted.

And, within a year or two everybody in the committee just sort of started to slowly tune it out, because they just recognized hyperbole when they saw it. I mean, here's somebody who never saw, you know, a new piece of equipment, or some new technology, or something else that they didn't want, and they basically made it into a life-or-death situation, when most people in the room were sensible enough to realize that it probably wasn't.

So, when you talk about credibility, how did I get my credibility originally with the leadership when I took over this position? I was on that committee back in those days, and we would go through, and we would say, okay, we need 30 incubators in the NICU because they're all breaking down, and we have babies that we're having to do emergency transfers, and this and that. Or we need a new something in the OR, which is broken and it's not fixable, or we need a new ultrasound machine. And our ultrasound machine was good, but it was a little dated or whatever, and so I would just sort of say it seems to me the fairest thing to do is to really the priority ought to be the NICU, or it ought to be that other service. And so I was able to sort of get beyond my own requests and say if I was running this hospital, what would be the thing that I think is most important? And it's for safety, or for patient care, or whatever it might be? And so, by doing that over a number of years, I mean, the president of the hospital used to say, You're one of the only chairs who can actually see beyond what they want, and that you can, you know, you can actually see the bigger picture, and I appreciate that so much, you know, so I want to give you something. Next year, we're gonna give you that new PET scanner, because, you know, you've just been great all along.

So you build up goodwill, and this is why committee work at your hospital and interacting at a whole range of different things is so important. The same thing applies in tumor board. We can't fix every problem in tumor board. You know, every problem is not a nail. But sometimes you're on tumor board, and you see that the radiation oncologist has an answer for everything. I'm gonna irradiate that, I'm gonna irradiate this, I'm gonna radiate that. And after a while, people begin to recognize that it isn't necessarily sound judgment that's behind that. It's more sort of the parochial, I know what I can do, and therefore I want to do it.

So it's very important to establish both administrative credibility, but also your clinical credibility. People need to understand that you use judgment, and they send you a patient, and you might send the patient back saying, we could do this, but this is really not the best thing for the patient. This is what I recommend.

It is amazing how far you can get by just looking at it and saying, what is what's really best for the patient? And try to put aside your own RVU count. Or your own ego, or your own whatever is driving you to do more of the thing that you do.

Moaz Choudhary, MD: Yeah, I think, you know, I think you nailed it, Basic, but look, as leaders, we need to look at the bigger picture and beyond your own department, so I think that's definitely some vision points for me, too. Now, you also earlier mentioned that people want to work where they're treated with respect and fairness.

On a different note in today's hospital healthcare system, the demands seem endless. As interventional radiologists, we play several roles.

There's weekend coverage, contrast reaction across multiple sites, increasing service expectations. So, how, as a physician leader, do you recommend we should manage these growing pressures without burning out our teams?

James B. Spies, MD, MPH, FSIR: This is a key problem. This right now, in both diagnostic and intervention radiology, is the key problem. There's a shortage of radiologists, there's a shortage of IRs, there's even a greater shortage of diagnostic radiologists. And I think there's a number of reasons for that.

Number one. For interventional radiologists, we're here. We're in the hospital. We aren't out working in some surgery center only doing, you know, elective gallbladders, or whatever it might be. We're here. And so people begin to understand what we can do, they trust us, and we become the resource of last resort.

So, I'll give you an example. You know, we had requests from the neurosurgery service that their baclofen pumps that were basically being used to put in medication into the, you know, the epidural space, they were getting clogged up, and would IR fix them?

Well, we have no training in this, we have no knowledge, and we didn't put them in. Why is it that we would be qualified, or think we would be qualified necessarily to fix these things? The same with lumbar drains. Why would you want us to be putting lumbar drains in when that's something that you all do regularly, but if it's nighttime or weekend or whatever. So, we've all experienced this, you know, what can be done by a clinical service, you know, 8 to 5 on a Wednesday is completely different than what can be done on the weekend, obviously. I think that that's one of the things, the demands for us goes up.

In addition, for IR, the biggest problem I see is that these health systems are gobbling up hospitals left and right. And they're getting a 100-bed hospital here, and a 100-bed hospital there, and their entire goal is to serve the simple needs of the community there, and then transfer all the sicker patients to the big centers, and this is a whole model for how they're going to be able to be sustainable.

And I get it, and I actually support that general model. The problem is, is they say, we need an IR there. Well, you know, you're a young IR that I'm trying to recruit into my practice, and I  and they, wow, I could work at Georgetown, this is great. And I say, well, yeah, no, actually, we want you to work over at this other hospital, which is 80 miles away, and it does 15 cases a week, and most of them are lines, ports, and a few drains. Occasionally you'll get a nephrostomy, and we want you to be happy. And, you know, it's pretty hard to offer that service, so

I've actually given lectures on this before, but how do you manage that? We have 9 hospitals in our health system, and we cannot provide 24-7 IR service in all those places. It is just impossible. We can't keep the physician staff, we can't even get enough technical staff to cover those hospitals, and that's another problem.

One of our hospitals. We actually have the physicians to cover. But there aren't enough nurses and techs. They can't cover nighttime calls, so they just, you know, we had to come to a collective decision. We're not offering emergency services there. They just aren't available. If the patient needs to have something done, they have to be transferred to another center.

So, managing that whole idea of, I've got 8 or 9 hospitals, how do I manage this?

You can offer IR, elective IR services like biopsies, etc., a couple days a week. You need to have some backup situation so that you're going to go out there and do a few biopsies, and then the patients, you know, if there's a problem, the ER and the other clinical services are going to have to provide you clinical backup.

Because literally, you might drive out there 50 miles, do 4 biopsies, and drive back, and then when you get home, there's a call saying, well, the patient's dropped their pressure in the recovery. You know, so those are things that you have to think about and work out. But you are providing a service for them, which they appreciate, and therefore building a cooperative means of supporting the patients is usually doable. So you do that. Still, that's not a great IR job satisfier, and so what we tend to do is we rotate our IRs and give them a day or two a week in the larger centers, so that they'll actually be able to have a full practice. But it is a management problem, it really is. And there is a constant struggle to be sure that our radiologists are productive. At the same time, they're not getting burnt out. And we come up with ways to be able to do that, but it's a constant process of trying to improve the working environment for everybody, and it, as I said, both on the IR and the DR side.

Moaz Choudhary, MD: Yeah, and I 100% agree. I think the volume and ER volumes are up, and then patients just get imaging before they get examined. That's a very common theme we hear. So, you know, along the same lines, you know, you mentioned that it's a constantly changing environment, and, you know, while some battles you can fight, sometimes you think it is--I think it's appropriate change.

So, what I want to understand is what's your internal personal framework as to evaluating decision whether is this the right one or not?

James B. Spies, MD, MPH, FSIR: Well, I think you have to take this from the perspective of, you've built a team, you have an IR team, so let's just say you're a young section chief, and you have 8 interventional radiologists, including yourself, and you're providing great services, and you're covering 3 hospitals, say. What you can't do is take that 8 people and cover, you know, 4 more hospitals. And you may not be able to go out and find those people. So, what you have to be able to do is say, what are the things that are going to be potential death blows, not to be too dramatic, to this group. In other words, what change could precipitate one or two or three of those people saying, this is not worth it, I'm leaving. And so this is where you have to have discussions with people, you have to have your ear to the ground, you know, take the barometer of what is the level of stress that people have with their carrying every day, and what are the frustrations they have?

So your general rule of job is to take the frustrations that are there every day and try to improve them. And those are things like, well, you know, we're short of nurses, you know, you work with the administration to be able to get some travelers or other things to supplement.

You can't get anesthesia enough, you work with anesthesia to be able to get their support services. You don't have enough beds and recovery, so you work on that. I've faced all these things over the years. I mean, I used to have UAE patients that we would recover for, like, 5 hours in the procedure room, because there was nowhere to put them in the hospital, because the place was over full. So, I mean, this is 15 years ago. And more than a few times, I walked in my  in my gown with my gloves on into the president of the hospital's office, saying, I've got no bed, I've got no bed. That wasn't the most productive way of doing that, because once that's dramatic, you do that 2 or 3 times, and they think you're a nut and a pain in the neck, besides.

So, all those kinds of problems, you have to work on those, and then when the hospital come and says, okay, we want you to do X, you know, something big, then you have to basically talk with your group, saying, “This is what we're being requested to do. How can we address this problem?” And if we're going to address it, what additional resources do we need?

Now, there's something that people don't often think about, which is that if a hospital wants a service and you can't cover your expenses by offering that service, you know, internally, they should pay for it. Basically. They should basically give you a supplement and say, okay, we want you to cover that hospital for calling, you know, it's gonna cost a few hundred thousand dollars over the course of a year in order for us to provide the service, because here are the numbers, this is what it would take. So those are things that I think it's important for people to think about is when you get new things that are big changes. You have to stop and get input from your group, and let them know you're going to try to come to a solution. And the answer may end up having to be no, or at least no for now, because this is the consequences of this would be the following things.

Moaz Choudhary, MD: Yeah, I think that's very well said. I think that conversation is really important to understand what the group feels, and then I think, like you said, you know, no or no for now, unless we get these resources.

James B. Spies, MD, MPH, FSIR: Yeah, and I can also say one thing, just to add on to that. There's nothing worse than going to your group, and you've had 12 meetings about something, and then you come to them and say, okay, this is what's happening, this is going to change, you know, you don't like a tough break. You know, the kind of imposition of your will and your decision on the group without them having any ability to give feedback, to be able to think of alternatives, just to express their frustration, anything is a recipe for disaster. You've got to have good communication with people, and you have to respect them enough as your colleagues to the extent you can, include them in the discussion.

Moaz Choudhary, MD: 100% agree, and yeah, that's great to hear that how you've dealt with these challenges. Along the same lines, you know, I know you and I, we've talked offline often about these, is, like, I think communication, conversation. I think one of the hardest part of being a leader is having difficult conversations.

So what advice do you have for leaders to, you know, approach the situation like a difficult colleague, or a colleague not meeting expectations. And, you know, how do you talk to those people, and maintain compassion, and also hold accountability.

James B. Spies, MD, MPH, FSIR: Yeah, it's not easy, and this is one of the harder things to do. I mean, I've had to essentially terminate quite a number of people over the years. I mean, probably, I'm not maybe half a dozen, or maybe 8 or 10, I can't really give you a count right now, but there are people that are not a good fit for your practice.

They may not be a good fit for any practice, but certainly you have to recognize when they're not a good fit for your practice. So, the first thing is, if someone is a problem you have to understand the problem, and once you understand whether you have, you know, 4 or 5 people complaining about something or whatever, or the texts are coming to you, or something's occurring, then you need to get them in your office, in a quiet place, and with respect, meaning not angry or shouting or whatever, but with respect, saying, it's come to my attention that this is what's going on, and what's happening. Can you explain this to me? What exactly are your thoughts about this complaint that has occurred? And let them give their two cents worth.

And, and so you make it to a discussion, but then the biggest mistake people make is they go too easy. In other words, they just sort of say, well, I'm sure it's not a big deal, don't worry about it, but I just wanted to make sure you knew about it. That's not a solution, because you've just validated whatever they're doing. So you have to say, I understand your point of view on this, and in some ways, I can even sympathize with it, because I've been there myself occasionally, but you can't do that. It's not allowed. We can't have that. It's too disruptive. I'm getting too many complaints. You are disrupting the work environment. You're creating a negative environment. You've got to work on fixing this, because it's bad for the group.

And what your job as a leader is to make it a good environment for the group. I mean, that is a key thing. If you have one person that is a problem in an eight-person section, it can just poison it. It can turn it to the point where people do not want to come to work because they don't want to deal with this difficult individual. Whether that's anger, or whether that's deviousness, or dumping work on you, or all other kinds of, you know, human behavior that's out there.

It can't be tolerated in the long run. And I learned this early on because, you know, I felt terrible in this one circumstance many years ago.

There was a problem, and I thought it was more limited than it was, but anyway, I had this problem, and it didn't seem to get fixed, and I just called that person, and I said, you know, I think it's time for you to think about somewhere else to work. This is not working, you're not a good fit. And, you know, we went through this whole process. And of course, when you're doing that, you have to do it with respect. What I used to do is I would say, well, I think you need to look for another place, but I'm not going to tell anybody about this. What I'd like you to do is go out and find a job. And when you find a job, let me know, and then I'm going to announce that you're leaving to go to this new job. You know, I never tell people that I've terminated someone's contract. You don't do that. But you don't want them just to disappear, either, unless they've done something horrible.

So, you want to make it so they can leave with some degree of dignity, with their reputation reasonably intact, and a fresh opportunity. I usually tell them, you know, this new job you're going to, this is your chance to remake yourself. Anything that you, you know, that occurred here, you don't have to do there when you go to that next place. So just think about it, because that first impression, or the impression you make in the first few months, is going to stick with you for a very long period of time.

So, being  direct enough so that they get the message. The other thing about leadership is that eventually, there's a small group of people that cannot change. And if they don't change, then you have to have those discussions. And it's more complicated these days. Now, you know, we have to have documentation, and oh, there's not enough, etc., etc. But still, the underlying issue is you have discussions with them, you tell them the key and truthful things that are happening from your perspective and why they're not tolerable. And what you need them to do. And then you document that discussion. And you don't have to send them an email, you just document it, you can put it in the file.

But you need to have those kinds of things documented. If the person turns it around and they're great from then on, terrific. Stuff stays in the file, you don't need to worry about it. But in general, you need to be more direct with people than you want to be. It's very hard to have that difficult conversation. But if you keep your tone normal, and you try to look at it from their perspective, you know, you can at least get on the level of the individual that you're trying to help.

And, in general, it doesn't become totally confrontational. Occasionally, it can, and if it does, it does, and then you have to just be tough enough to deal with it.

Moaz Choudhary, MD: Yeah, I mean, these are really valuable points, and I'm sure they'll be very helpful for not just early career, mid-career, and other senior leaders, as we all kind of shy away from these conversations.

So, let's come towards the end of the episode, I want to ask you, like, you know, you've had a tremendous career. When you look back on your career, what kind of difference do you most hope to have made, you know? Like, do you think, like, are you very excited about the department you set up, or that you helped make a UAE procedure that is widely acceptable? What do you think really gives you pride?

James B. Spies, MD, MPH, FSIR: Well, you know, there are a couple things. One is, and it isn't my accomplishment so much as it's a team accomplishment, but I would start with my department and say that we have a great department.

We have a very collegial environment. We've worked hard to maintain that environment. In fact, the number one concern—I've just done annual reviews recently, and had, you know, I have an individual meeting with every faculty member every year, sit down for a half an hour, kind of talk through things, and talk about their academic career, etc.

And the number one thing they're worried about is that with my announced retirement and a new chair that things are going to change, because they're happy with the way they are, and that's a source of pride for me, but it isn't something I created. It's something we created as a group.

And, they deserve as much credit as I do. So, we were able to attract good people who were put into an environment where they're working with other good people, and they became friends, and they work with each other, and they help each other out, and help for, you know, with family emergencies, other kinds of things.

So they become, you know, it's like your office family, and so we have a great group, and I'm proud of that. I think UAE in general, although, again, that's a group effort. I mean, I've done a lot of things in UAE, but there are lots of people around the world, lots and lots. I mean, I would not be doing this if it was not for Scott Goodwin, you know, who at UCLA announced the first cases back in 1997. I saw his first presentation, and I got excited about it, and I came back, as it was at the annual meeting of the SIR, and I came back here, and started the protocol, and started working on it.

I did lots of things with Scott, lots of things with other leaders in the SIR over the years. We did the fibroid registry, etc. But if you're going to say, what is the one thing that I've done that is probably going to stand the test of time the longest? It may surprise you a little bit, but it's the questionnaire that we created.

The SIR Foundation had the good sense to respond to our research consensus panel that said at the early days of UAE, that there is no validated questionnaire to assess the symptoms and quality of life of women with uterine fibroids and the outcome from the treatment. In other words, the change that you'd see in that. And so they gave me a grant, and I work with what's called a pharmodynamics company. They create patient-reported outcomes measures. And we created this questionnaire and went through the whole process to be able to do that. That questionnaire cost the SIR, $50,000 and a grant, basically.

Now, you couldn't do it for $50,000 now, but it's $50,000 at the time, and they've made probably hundreds of thousands of dollars in licensing fees ever since. It is the number one questionnaire across the world for assessing fibroid outcomes. There have been hundreds of drug companies that have done drug trials, or device trials, or other kinds of things using that questionnaire. There are tons and tons of studies that have been done around the world by clinicians like myself, using that questionnaire. Gynecologists, you know, all the whole range. That is a real legacy for the SIR Foundation, that they actually created that, and they allowed me to create it, but really, the leadership at the time really deserves credit for what really is a fantastic instrument. It's now managed by something that's called the MAPI Institute in France. I still occasionally get requests, and I direct them there, but there have been probably 2 or 3,000 clinical trials that have used that questionnaire. So, that, I think, has had the biggest impact.

Most people don't really think about that when talking about UAE, because they're just talking about taking care of the patients, but it's a great tool.

Moaz Choudhary, MD: Oh, that's good to know. I mean, yeah, I've seen it, and I've heard really great things. I mean, not just from personal experience, but other people across the country who practice IR.

We’re towards the end of our episode, Dr. Spies, thank you so much. You know, we really appreciated having you on this podcast. Just one last question.

You’ve seen our specialty grow into primary specialty recognition by ABMS, then our primary residency. You know, what do you think gives you optimism about the future of interventional radiology?

James B. Spies, MD, MPH, FSIR: Oh, this feels unbelievable. I can tell you, just about everything I was trained to do back in the 80s, we no longer do. And everything we do now, almost, was not done back then. I mean, it is an amazingly innovative field, and it is filled with people with great innovation, talent, sense, and problem-solving skills.

I have to say, this is a fantastic group of people. I mean, it clearly, to me, is the best field of medicine, because we are on the cutting edge of so many different things. We just are a very practical group that can figure out solutions to complex problems, and we do that every day in our practice. I also have to say that this is a great group of people. I mean, I tell this to my wife all the time. I have friends here in Washington, D.C, and, you know, people we go out with and stuff, mostly my wife's friends, I would say, but anyway.

I walk into the SIR, and I cannot walk across the, you know, the expo hall without stopping and talking to 30 or 40 people that are my good friends. When I walk in there, that is where my friends are, that is where my heart is, the SIR and the people that are there. I mean, it is a great group of people, and you get to know people so well over the course of a career. It's just been fantastic.

So, I thank you, and I thank the SIR for everything everyone has done in this field. I mean, it's great. I'm excited that the newer generation is listening to things like this, because we've had podcasts back in our day.

You know, it's funny, this is probably the first podcast I've ever been on, but I will say that it's fantastic, because the people that are listening to this right now are the future giants of our field, and they're gonna do great things.

Moaz Choudhary, MD: Definitely, and you know, we're lucky to have people like you lead our society and our field, so thank you.