Interview with Frank J. Criado, MD

LG: What are you doing now? What are your primary areas of interest? FC: As you know, I am a vascular surgeon by training and background. However, along with a few of my peers, I began to develop an interest in performing percutaneous non-surgical procedures in the mid-1980s. In a short time, this “interest” became my raison d’etre as I totally embraced intervention in all its expressions. So, what and where I am now reflects such evolution that occurred in my life and practice over the past 15 years. My own personal practice today consists of 75–80% percutaneous diagnostic and therapeutic procedures, and 20–25% conventional vascular surgery. Nonetheless, surgery overall is a very important part of what the whole team does in our department. As to myself, I kind of “live” in the angiosuite; my “bunker-office” is in fact right across the hallway from the interventional suite. I recognize of course this sounds a bit strange, that is, a surgeon whose practice and daily routine are largely connected to catheter intervention rather than cut-and-sew surgery! We do all diagnostic angiograms on our own patients, quite a bit of cerebrovascular diagnostic and interventional work — including carotid stenting, renal artery procedures, iliacs and lower extremities, and of course, dialysis access interventions. I am also very active in the field of stent-graft procedures in the abdominal and thoracic aorta, with multiple IDE industry and site-sponsored clinical trials. The research side of our department has grown tremendously over the last few years, with 2 full-time clinical research coordinators (looking for a third!), a research associate, research assistant, etc. Additionally, our group is extremely busy with presentations, publications, and many training programs for physicians and industry. LG: Who is at risk for AAA? Are the risk factors the same as for coronary artery disease? Are these aneurysms becoming increasingly common? FC: AAAs are some of the most important lesions we treat in vascular surgery for reasons of high incidence, and because they can be life-threatening. We can literally save many lives through timely detection and elective treatment of AAAs. They occur in about 2% of males over the age of 55; it doesn’t sound huge, but there are an awful lot of men over 55 out there! Women are affected too, but with a somewhat lower incidence. There are well known risk factors for AAA development, such as a family history of aortic aneurysms, smoking and COPD (often related to smoking as well). The familial connection, or genetic predisposition, is relatively new knowledge for us, but a terribly important piece of information from a clinical perspective. It is known that as many as 1 out of 5 cases of AAA may be patients need to be informed that their offspring (and other blood relatives) may be at risk; they need to know this, and should probably undergo ultrasound screening, particularly after age 55. AAA rupture continues to be the 13th leading cause of death in the US. LG: Tell us how you got where you are. First, tell us about your childhood. FC: I didn’t have one! (just kidding…) LG: You were born a vascular surgeon? FC: I suppose that in some ways you can say that! I was actually born and grew up in Uruguay, where I became an MD in January 1974. I stayed in Uruguay for another year or so as a post-graduate surgical resident while awaiting my planned move to the US. I wanted to come to this country to pursue a surgical career. The vascular specialty was not yet on my radar screen at the time; this evolved during residency in general surgery in Baltimore — it became clear as a PGY-3 resident, I think. LG: Did you intend to return to Uruguay after you received further training? FC: Well, it wasn’t all that clear to me at the time; I had not made up my mind one way or the other. I kind of thought in the back of my mind that something might evolve (but only God knew what it would be!). The rest is history: I made a life in this country, and the thought of returning to Uruguay did not cross my mind ever again. I still go back for visits and meetings, and enjoy every minute of it, but that’s it. In any case, I came to the US in June 1975 and did a 5-year surgical residency at Union Memorial Hospital in Baltimore. There is a requirement to go through that kind of training to become a surgeon — my lifelong dream! The pursuit of the vascular specialty evolved mid-stream during the residency (by 1977 or so); and I decided to go on beyond general surgery and embark on a fellowship. In those days (1980), cardiac and vascular surgery were often together, and that was certainly the case at Baylor College of Medicine in Houston where I secured a position as cardiovascular surgical fellow for one year at the Methodist Hospital under Dr. Michael E. DeBakey. Having completed the fellowship on June 30, 1981, I returned to Union Memorial in Baltimore to become the Assistant Chief of Surgery. So, back to Union and to Baltimore where I still am today! I started my own private practice at that time as well (July 1981), and was lucky enough to form a partnership with two other, very well established surgeons in the area who offered me the opportunity to be an equal partner from day one! As Assistant Chief, I had administrative and teaching responsibilities — Union Memorial Hospital has its own surgical training program; it is in fact the longest running non-university, stand-alone surgical residency in the US. I held this position for five years, until my practice became so busy that I could no longer discharge the duties. A few years later, in 1988, I created the endovascular program which became, several years later, the Center for Vascular Intervention, of which I am the Director. Additionally, since 1994, I have been the Chief of the Division of Vascular Surgery. LG: What was it like to work with Michael E. DeBakey? FC: It was fascinating and different in many ways. At the time (1980–81) one could still experience the tail-end of the good-old days at Baylor. That is, the unbelievably busy surgery schedules, 100+ inpatients on the senior attendings’ services at any one time! Patients and visitors from all over the world were coming through. It was awesome to be in such a place, and work right across the table with surgeons who had literally helped develop a good bit of our specialty and trained many if not the majority of vascular surgical leaders who then spread all over the country establishing vascular surgery as a specialty. I thought it was the right place to be, at the right time in my life. However, I did not enjoy living in Houston and in that environment in general, and would not have considered staying there. In fact, I was quite anxious to get back to Baltimore and “my” old Union Memorial. But please don’t misunderstand me: I am very appreciative for the opportunity I was given to work with Dr. DeBakey, Dr. Crawford, and other legendary figures in American vascular surgery. It was a life-changing experience for me, and for that I will always be grateful. Interestingly, it would not have occurred to me for a minute then that I would, one day, look upon surgery as a thing of the past in my life, and become more interested in non-surgical procedures — in some ways “rejecting” surgical heroes of my past, to admire and feel closer to non-surgical interventionists! It is almost incredible that this would happen to a guy who wanted nothing but to become a surgeon since he was 18. The term “endovascular” had not even been coined then; balloon angioplasty was in its infancy. Worse yet, it would not have been considered “worthy” of a surgeon... You may find it interesting that this concept, meant as a tongue-in-cheek expression, continued to be foremost in the minds of many surgeons I know until very recently! LG: If you hadn’t chosen to be a surgeon or a physician, what do you think you might have chosen for a career? FC: Since I have been a doctor for so long — or so it feels — I’m not sure I ever had a serious “discussion” with myself about another direction or goal in life. Perhaps I should have, but I don’t think I did. I kind of remember my parents, my mother in particular, talking at times that I would become this or that or the other. I think she wanted me to become a lawyer or the like. I never committed myself, and kind of brushed her off when she would start talking about careers and goals. As a young boy, say from ages 9–16, I recall becoming enamored of literature, philosophy, and politics. The idea came to me that I would become a writer. I remember looking at and touching books (in addition to reading them!), thinking of how nice it would be to see my name on the cover as editor or author. I used to say to myself, “Gosh, having a thick, well-written book with my name on the cover… It just doesn’t was a busy but relatively straightforward surgical practice. I was not performing the hundreds of procedures I do today, or teaching as much, or puncturing, researching, planning, writing, traveling, and a few hundreds other things I now do on a daily basis…This relates in part to what some have termed “the yes syndrome.” But you know, we all have difficulties saying no because of the well-founded view that we got to where we are through saying yes! Regardless, I need to start saying no a lot more often, and correct the growing problem I’m beginning to have related to over-promising and under-delivering… The dictum, “when you need something done, go to a busy person” still holds true, but there are limits. A lot of my colleagues will understand immediately if you mention the syndrome; it is rampant! We just have to learn to say “No, I am sorry. I just can’t do it right now”. LG: Editors do appreciate that. FC: I know, I know! Because for me to say “yes” and then not deliver is a lot worse. At the end of the day it is a lot worse for you, and for me, too! I have to learn to say, “I’ll pass on that. Next time come back to me and I’ll probably do it, but I just can’t do it now.” Yet many of us will continue to say, “Sure, I’ll do it.” Later we’ll say, “Oh my gosh, that is due when? Next Monday? There is no way in the world I can do it!” But yet, you go back to your records and see that you promised — and that is when you go crazy. That multiplies itself, and so we end up in that situation all the time. It’s just not good. I and many others need to manage that better. However, I am getting a little better. I have turned down a couple of things just recently that I couldn’t do, I just couldn’t do. “Would you come to Japan next week?” “Sure, of course!” Then you say to yourself, “How am I going to do that?”, I have to be here on Monday. That type of thing. LG: That’s a lot of stress. How do you keep yourself in good shape and... FC: Sane?! LG: Yes, sane and healthy! What kind of fitness routine do you have? FC: That is difficult. It is difficult to keep any sense of discipline. I am fairly structured in my daily life, although it is kind of messy and very busy. I have a sort of routine that enables me to go through very long days and still keep the focus and the necessary level of alertness. I often work out, for instance, at 8 or 9 o’clock in the evening after a 12 or 13 hour day. Some people would find that crazy to put themselves through such a schedule. LG: It can be hard to get to sleep if you work out later in the evening. FC: I have the ability to function on very few hours of sleep, sometimes only four or five hours. Without that ability, I couldn’t do anything. I often go to bed by 12 or 1 and I am up by 6 or 6:15. And I function reasonably well. LG: Do you catch up on weekends? FC: I do catch up sometimes when I’m in town, and stay in bed until 8 or 8:30 AM. Unfortunately, I travel 1–2 weekends out of each month. I find exercise and physical activity critically important to maintain strength and for endurance. Also, it helps me overcome, or even avoid jetlag altogether. When I go to Europe, for instance, I try to go for a long run shortly after arrival; this gives me enough energy to function all day and stay up until my normal bedtime. It is very important to resist the temptation to take a long nap; it will decompensate your whole rhythm, keep you awake at night, and then you’ll be tired again the next day, etc. LG: Do you run on a treadmill or outside? Exposure to daylight can also help you adjust to the new time zone. FC: It depends where I am and what hotel I am in. That is why I got into running. I never liked it before and I still don’t like it all that much. But when I started traveling a lot, I found that you can do it anywhere. Except for heavy rain, you can do it anywhere. LG: And it’s fast. FC: Right. In 30–60 minutes you can get a good workout. LG: You run for 60 minutes? FC: I used to run for an hour or longer, doing 8-minute miles. My current routine is a little less demanding, but I continue to exercise pretty hard several times per week, and virtually every day while traveling. I feel fortunate these old joints and legs of mine can still take the abuse quite well. LG: Do you remember the last time you were sick with the flu, or something like that? FC: I never get sick. That is another way I am very fortunate. I get colds occasionally. Several years ago, I used to get colds all the time. I don’t know if it is because I take vitamins or what, which I do. LG: What do you take? FC: Multivitamins. I don’t know if this is the reason, but I only get colds once or twice a year. I certainly never “call in sick.” I would have to be really ill to not show up or deliver on a commitment; my only option would be to “call in dead.” The last time I didn’t show up for work was one day 12 years ago when I had a 104° fever. I suspect that after all these years of absolute health, one day, I’m just going to get really sick and that will be t! Hopefully, it won’t happen any time soon… LG: What is the biggest problem or challenge that you face in your career or in your practice? FC: The biggest problem I have is perhaps the issue of balance in my life in general. This relates to the multitude of activities and commitments — almost too many to mention! Balance is indeed a valid but elusive concept for me: too many balls in the air, all at once! Some may wonder, “why not just go back to being a surgeon, and take good care of your patients: isn’t that enough?” Well, it is not enough for me at this point in my life; I would not be happy. I have to do more, and be different. I am what I am; it has been a natural evolution, not really a conscious choice. And for the most part, I like it this way! The problem is that while offering enormous opportunities in terms of rewards and satisfaction, being so busy can generate an almost equally large number of potential mishaps and unhappy occurrences. But that’s the way life works! LG: What else? FC: The second biggest challenge it seems for me, and for many others, is economic. So many of these things that we do are non-revenue producing activities. So we have to keep an eye on that, because we cannot be using 80% of our time on efforts that do not bring any income. Somehow all of that machinery needs to be supported. Therefore, it is very important to keep that in mind. LG: What about the balance of work and family? FC: I have found it impossible to keep or even approximate any kind of balance in my life. You just can’t do all this and be a perfect family man at the same time; I certainly can’t, and that’s unfortunate and regrettable. I think about it often, and it continues to bother me a great deal. It is almost surely the single worst implication of such a busy career. A “sacrifice” if you will. I can only hope my family and the children in particular will one day understand what it takes to do what I do, and perhaps appreciate its significance, and how it can impact the lives of many. LG: Did your wife know what she was getting into? FC: No, no — because all of this has evolved over 20 years. Nothing happens just like that. You do not always evolve together with whoever you are with. That is a real problem, but there is nothing new about that. A lot of my colleagues, and we often talk about that, have the same problem. That is a real issue. It was a little better when the children were young; I was a little less busy. Right now, obviously, they have their own lives or are beginning to have their own lives, and very often when I am available, they have their own interests and commitments. LG: How old are your children? FC: The boys are 19 and 13, and the girls 17 and 15. All very close in age. It is a big and busy family indeed! LG: Since you travel so much around the world, I am curious to hear what is your favorite country or city to visit? FC: I could think of many different places that I find interesting if not fascinating. But I will mention only one: Paris. My favorite city for sure! I must tell you I have an inclination for French culture and the French language. I go to Paris several times a year; it’s always exciting! I often spend 2–3 hours in a café doing essentially nothing. Perhaps reading the paper or just watching the people along a street in my favorite neighborhood of Saint Germain-des-Pres in the left bank. I have come up with some the best ideas and planning while in Paris…with the exception of the really good thoughts I get while running anywhere! (Paris included). LG: I know you are fluent in French. Do you think in French when you are in Paris? FC: No, I think in English! But I am able to communicate in French. Which is probably one of the reasons I enjoy it so much. LG: When did you learn to speak French? FC: I actually studied French for a number of years as a young boy; my mother made me! For some reason I rejected it then, and was even angry that she wouldn’t realize English was the important language — although this was not considered “conventional wisdom” in that part of the world in the early 1960s. Again, for reasons that are not very clear, I became progressively more interested in the French language and culture many years later, after the move to the US. This came to a head about 10 years ago, to the point that I just had to do something about it. I suppose one precipitating event was my first visit to Paris (and France) in 1989, when I felt inadequate and diminished in many ways for not being able to communicate in their language. So, I set out to remedy such a flagrant handicap; I found two venues right in my backyard, in Baltimore. I learned that Hopkins offered some excellent evening courses, with levels from beginner all the way up to advanced conversational skills; so I did this for several years, somewhat inconsistently due to my very busy life, but I managed to get a lot out of it. I also found out about an organization called La Causerie, where French-loving people get together once a week to discuss, practice, and improve their “French skills.” Each group is usually lead by a retired French teacher, or someone else similarly qualified. It was a great experience. But what really rounded up the process for me was the development of rapidly growing connections and friendships with colleagues in France, as well as frequent travels to Paris and other parts of the country when I was able to achieve vast and quick improvements in my ability to communicate in the French language. In the space of just 2 years or so, I was able to achieve quite a good level of proficiency, and became conversant in such a different language. And to the extent that I could watch newscasts on French TV and understand more than 90% of it, and even make scientific presentations at vascular meetings, in French! I must tell you it was a very interesting and rewarding process for me. The fever and unstoppable urge for all things French has subsided, but they remain very close to my heart and in the back of my mind, always. Every time I return to France, or any other French-speaking country, I am happy to re-confirm that I can get it all back in the space of 1–2 days and start speaking again. Being a native Spanish speaker helps, without a doubt. Interestingly though, when I went through the learning process I just described, I did so from English, because English is “where” I live and function. My dreams, when I remember them, are also in English. Now, consider this: French is a lot closer to Spanish than to English. So it would have been easier for me to learn French with the Spanish language in mind, but unfortunately I couldn’t do that. In any case, it worked! I don’t want to be too boring with this, but I must tell you that the “French experience” in me must be viewed within the framework of how I approach things I am passionate about. I go all out and never stop until attaining the best level of achievement I am capable of in that particular field. Surgery was of course, for many years, an excellent example of that; but I can also mention racquetball — my absolute passion for about 8 years starting from 1982 on — quitting smoking (which I did 20 some years ago), and now endovascular intervention. Racquetball kind of dominated my life for several years; I picked it up relatively late in life, but I managed to become very quickly an excellent player, even to the extent of traveling to California to play in tournaments. It was one of the best examples of how I behave when I decide to embark on the fierce pursuit of what I want. Hopefully, I will experience again such urge and passion in my life before it’s over… LG: When did you learn English? FC: I studied it in a real serious way beginning in 1973, once I had set out to come to the US. Once again, I did it in a totally intense and relentless way: “total immersion” as it is often described. LG: Your English is very good. FC: It is acceptable, but not as good as I once thought it should be. The thought of “losing my accent” (or “overcoming” it, some might say) swirled around my head for many years in the 1970s and 80s. Regrettably, I never got around to it. Speaking with an accent, you know, is essentially inevitable when you learn to speak the second language after puberty. LG: What is your favorite travel destination in the United States? FC: There are, of course, many areas that are beautiful and worth going back to. Examples include the San Diego area, wine country in northern California, the bay area, and many others all across this vast American land. But I must tell you very specifically about one little spot in Newport Beach, California called Balboa Island. My wife and I discovered it a number of years ago, and have been going back there for summer vacations with all the children ever since. It is a bit crowded, but absolutely unique and fascinating. We love it. LG: How do you pass time on airlines? I assume you sometimes review and write manuscripts. Do you ever read fiction? FC: With few exceptions, I do not enjoy (modern) fiction. I prefer reality reads. I also prefer history books and writings over futuristic ones; a sure sign of aging I suppose… Something that often worries me in this area relates to availability – or lack thereof – of time to read books and absorb information that is not related to medicine or work! Several years ago, I made a valiant effort at reading a non-medical book of interest for at least 30 minutes each night, just before going to bed. I was pretty successful for 2 years or so, but I have since descended back into the depths of an all-vascular life…It can be depressing, and lead to extremely boring conversations for wives and others who couldn’t care less for the latest endovascular device or the prevention of restenosis after stenting… On the upside, though, I am pretty good at being well informed; I am kind of an information “junkie.” I read at least one newspaper every day, usually USA Today, because it presents the information in bullet format: easy to digest, brief, and no need to turn the page to complete reading an article! I hate that! I also like to watch TV, mainly news shows and philosophical/political-type debates. Once again, and all throughout my life, philosophy and literature stand tall in my mind, together with biology and related subjects. You may find it curious or strange but I like long flights! Time is passed in various combinations of eating, drinking, reading, writing and sleeping/relaxing. During really long flights, one can do all of the above in abundance! A recently found new tool for me is the laptop computer, which I now take with me religiously, wherever I go. I do mostly Powerpoint shows — which I keep “enhancing” and changing all the time! — but also use its word processing capabilities for manuscript writings, reviews, etc. It’s great to be able to plug your computer in while flying. LG: Who has influenced your career? FC: As you can imagine, I have been influenced by many over the years. A list of prominent ones would include DeBakey, Crawford, and Diethrich, to name but a few. My friends Bill Howard, Julio Palmaz, and Thomas Fogarty have been and continue to be very influential figures in my life. I have also encountered many significant individuals and companies along the “endo journey” of the last 15 years, but it would be impossible to name them all. It seems clear to me now that what we are, what we have become, is related in large measure to one’s own unique abilities and attributes, but — at the same time —we must openly acknowledge the significant external influences that have converged on our lives over the years, contributing to the final make-up of the complex and composite reality which we call “me” or “I.” I also want to mention one more pivotal influence: Dr. Ted Wilson, the former Chief of Surgery at Union Memorial Hospital in Baltimore played, perhaps, the greatest role of them all. He was responsible for my coming to Baltimore and this hospital in the first place! Beyond that, he was (and still is) for me a living example of an individual who could be a gentleman, a skilled surgeon, and a compassionate physician — all at once. LG: What advances do you see in the future? FC: The future holds plenty of both promises and challenges. The most important, almost obvious promise in our field is that we will continue to get better at treating vascular disease, and do so with less invasion and less pain. Technological refinements in equipment and development of new, more sophisticated, miniaturized devices also promise to continue at an ever-quickening pace. Some currently evolving technologies may prove to be “game-changers” in the near future; drug-eluting stents, and, perhaps, vascular gene therapy are good examples in this category. However, such likely breakthroughs may be matched by formidable challenges. For instance, stent-graft aortic devices, as exciting as they may be, are surrounded by a cloud of unanswered questions and growing doubts concerning durability of both the repair itself and of the very integrity of endografts over the long haul. Health economics are another major challenge, with potential to stifle technological advances. The high cost of endovascular devices is a major issue, and stent-grafts for AAA repair are the best case in point: it is difficult and at times impossible for hospitals not to lose money when the endograft cost alone is $8,000–15,000 per case! This has to change and very, very soon. In a more global perspective, ever-diminishing pay to doctors in general may lead to a significant “brain deficit” in medicine as bright, hard-working, ambitious individuals will be more likely to pursue non-medical careers. In the end, I don’t want you to take home the impression that things are not going well and that progress will not continue. Most emphatically, that’s not the case! While conventional surgery as we know it is not likely to go away in the foreseeable future, the trend toward less invasion is relentless and unstoppable. “Irreversible” may be a better word. While some of my surgical colleagues continue to have difficulties grasping the concept, it is plain that patients prefer not to be cut open when given the choice! Impor-tantly, referring doctors feel the same way. This vision was, in fact, at the very center of my decision to reinvent myself as a catheter interventionist 15 years ago. It has not changed. But to be completely fair, I must say that I view my continued ability to operate and surgical background as tremendous assets that enable me to advise patients with authority on the best course of action in a given situation. They also give me the kind of confidence one can only attain with the knowledge that I can bail myself out if necessary, and that I need not worry about forcing the surgical or percutaneous indication one way or the other, for I can do both.