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China in comparison to the United States | Across the Pond: The state of Interventional Radiology in China
China in comparison to the United States | Across the Pond: The state of Interventional Radiology in China
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Interventional Radiology in China | Across the Pond: The state of Interventional Radiology in China
Interventional Radiology in China | Across the Pond: The state of Interventional Radiology in China
chapterchinachinesedaughterdedicateddiagnosticinterventioninterventionalmedicaidmedicareproceduralproceduresradiologistradiologyrecoveryroughly
Most common IR procedures and disease in China | Across the Pond: The state of Interventional Radiology in China
Most common IR procedures and disease in China | Across the Pond: The state of Interventional Radiology in China
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Radiology equimpent in China | Across the Pond: The state of Interventional Radiology in China
Radiology equimpent in China | Across the Pond: The state of Interventional Radiology in China
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Hospital tier systems in China | Across the Pond: The state of Interventional Radiology in China
Hospital tier systems in China | Across the Pond: The state of Interventional Radiology in China
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Difficulties in provision of care for the Chinese Interventionalist | Across the Pond: The state of Interventional Radiology in China
Difficulties in provision of care for the Chinese Interventionalist | Across the Pond: The state of Interventional Radiology in China
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Innovation in Interventional Radiology in China | Across the Pond: The state of Interventional Radiology in China
Innovation in Interventional Radiology in China | Across the Pond: The state of Interventional Radiology in China
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Training of IR Physicians in China | Across the Pond: The state of Interventional Radiology in China
Training of IR Physicians in China | Across the Pond: The state of Interventional Radiology in China
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Observations working in IR in China | Across the Pond: The state of Interventional Radiology in China
Observations working in IR in China | Across the Pond: The state of Interventional Radiology in China
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Questions and Answers | Across the Pond: The state of Interventional Radiology in China
Transcript

good morning everybody's how's everybody doing today so I'm three coffees in you're gonna have to hold on for the ride it's gonna get pretty quick but what I am gonna do is gonna be talking a little bit today about the interventional market in China

specifically you know one of the things that I'm very blessed to do with my role that's of global roles I travel all over the place and dealing with colleagues and people overseas getting an understanding of how we do intervention

some places doing intervention overseas so I get a different perspective in China's a very unique market to do intervention for the interventionist for the patients and certainly for companies that are trying to come in to China from

the United States Great Britain overseas it's a different market something totally different than what we're used to here in the US now has anybody here ever traveled to China any hands well Christian put your hand down I know you

did excellent well I was gonna say if the room was full of people that traveled the China's gonna drop the mic and walk out get another cup of coffee but what we're gonna talk about a little bit is kind of my perspective on things

and I will tell you I'm a little non-traditional and how I do things just these right here in my my disclosures and like I said I do like long walks on the beach fluffy clouds cotton candy and I really do wish I

could grow a mustache like Jim kratie you guys like that mustache right pretty fantastic it's like Wyatt Earp come on you'll love that so let's talk about trying a little

bit in comparison to the US or try to at

least if I get this thing to work there you go so you know and compared to the US China the population is 1.3 8 billion so you're talking about a population that's for apps four times the United

States you know we always think about things and we think about everything we do in Western medicine and you know the vastness of that country and the amount of patients that are there I mean really it's its own income comparable you know

us you have thirty three twenty three point 1 million much less people you're in a much less diseased State 31 000 hospitals in China compared to us we got 6 200 hospitals really that are doing any type of case in procedure loads and

you talk about the size of the hospitals now they have very small hospitals you talking about 50 bed 40 bit hospitals and the world's largest hospitals actually in China as well it's 8 000 beds and they're predicted by 2020 to be

up to 10 000 beds in the u.s. the largest Hospital based on beds and I'm not talking about like systems or ID and so based on beds is New York Presbyterian Cornell will in their 2000 36 so you can kind of see that disparity

right there and when we talk about the Chinese population unlike what we see in Europe right now in the US or receive reduction in cancer rates across the board for multiple reasons new medications new interventions China

cancers rising and it's the highest rates of lung liver gastrointestinal cancers in the world make keep rising it's amazing when you go over there and we'll talk about this a little bit you know I went over there as you know a

Western colleague training Western ideology and medicine and you think you didn't go there and you're gonna be able to share all these new techniques I mean interventional oncology it'll blow your mind the number of procedures

you'll go in there on the board and they'll be 25 cases in one day for one practitioner to do so it's kind of the the amount in volume you can really learn a lot we're going to talk about that a little bit more in depth as well

so you know interventional radiology in

China first of all point out look how handsome that guy is right there right that's kind of that guy's a stud no a joke and it's me but anyway interventional radiology in China you

know largest procedural case volume which is quite interesting that 1.6 million procedures a year roughly do you guys have an idea of how many interventional procedures are done here in the u.s. that we consider peer

interventional a year none that's what I'm here for you if you knew that then I won't have to be up here right so anyway o Medicare Medicaid when we look at CMS

and kind of get a rough estimate and then extrapolate looking at that Blue Cross Blue Shield private payer so you're talking about well over twice the amount of cases done yearly in China compared to the u.s. an intervention it

definitely is the biggest future market for medical device innovation when you have that many procedures being performed on that many patients you're gonna need new products there's gonna be new ideas and new innovations

but there are some issues with that in China we'll talk about that that makes it a little bit complex for companies from the outside that have different products that they want to bring into China it can be quite a complex process

and I'll kind of explain that to you a little bit as well you know iris especially was introduced in the 1980s early 80s X News 1983 when it was brought into China and the gentleman who brought it into China actually trained

at the daughter so he back in 1968-69 met Charles daughter and they started having a pen pal relationship and he was brought over in 19 9 and kind of introduced irn to Chinese the grandfather of Chinese intervention

his name is dr. Peng so who's out of Shanghai he's passed away now but you know it's kind of interesting that little historical tie back to daughter you know and and roughly about 7 000 practitioners identified themselves in

China as I are now I will tell you that that could be probably speculative they could be doing if you're a biopsy guy and you're doing you know lung biopsies are you an interventional radiologist in China you are because their process a

little bit different in how they train and how they identify themselves and like I said the thing that's interesting in China they have a Chinese society of interventional radiology there's more members of that than there are but the

SI R so the and I can tell you when you go to their meetings they have a better turnout you know their turnouts about 6 000 members they kind of have to go they don't have much choice that kind of told you gonna go so it does help in

getting that that turnover but it's so you'd have a very large society and they're very well abreast of what's going on internationally and when we talk about intervention you know for many many years in the US intervention

was a subset tied to diagnostic radiology you would have your diagnostic guys you'd have an interventional group you may if you're lucky have one or two recovery beds that you can use down the same day surgery afterwards to send your

patients China has always been very progressive in how they set up their interventional procedural Suites roughly about 50 percent of all interventional radiology departments in China have their own dedicated recovery unit their

own dedicated recovery staff and 1/3 of those are actually their own department so when you go you're going to vir similar to what we have in some of our major large academic institutions where interventional radiology interventional

neuro is separate from the diagnostic radiology department so that's quite impressive like I said you go over to China and you're expecting you know maybe a little bit different things to be a little small or maybe a little

slower absolutely not and certainly from my experience that wasn't the case so

you know the most common procedures in China this is kind of interesting I was blown away by this when I did the research on this I knew when I would go

into the hospitals and I was all over for I've been to Beijing shanghai nanjing to even the smallest little place is up in northern china and the one thing that blew me away I'm looking at the board and I'm seeing neuro case

after neuro case after neuro case I'm like it got 10 Narrows and and a pic line I'm like it's an interesting interesting Dysport of cases and the reason being is in China they consider diagnostic neuro

so neuro angio to be the primary evaluating factor for any type of neurological issue so you're not getting a CT if you come in with a headache you think you're gonna go get that cat scan now it's generally what not what they do

so you're talking about a case and I'll give you the case matrix of the break-up it's just proportionately high for a neuro very well trained in neuro and most of the guys that are trying to neuro very similar to what dr. well Saad

said a lot of the guys in Africa are trained in France so other neuro interventions have trained in France or lipstick in China and have received European training on that so you know the level of what they're doing some of

the stroke interventions some of the ways they're going after these complex APM's they'll Rob well anything you'll see here in the US so it is quite interesting to see and the second

largest is taste hepatocellular carcinoma is on the rise it's the highest level in the world is found in China and Korea for that matter and there's many reasons why we can go into it some of it is genetic factors and a

lot of societal factors alcohol is a very liberally lie baited in China and there is problems with you know cirrhotic disease and other things that we know could be particular factors for HCC so always found that very

interesting like I said I would go into a hospital and I'll see a PICC line a hemodialysis catheter and then 20 tase's on the board in one day so it is quite interesting how they do it and then biliary intervention stents tips and

then lung ablation you know the highest rates of HCC biliary cancer and lung cancer found in China and once again when we talk about lung cancer what are those contributing factors you're talking about certainly a genetic

component but mostly it's lifestyle factors smoking is prevalent in the US and in you know in Europe and in some areas in Asia we've seen obviously a big reduction in smoking which is fantastic China not so much you don't see that

it's a societal thing for them and unfortunately that has led to the the largest rates of cancer in the world in lung cancer so lung ablation is a big procedure for them over there as well so procedure breakdown this is kind of some

of that breakdown I was telling you about that cerebral procedure is some of the most commonly performed and you're talking about at very large numbers they're doing neuro intervention because they do it for die

Gnostic purposes and I would that kind of blew me away when I found out they do have cast scanners and certainly for trauma and things like that they'll do it but the majority of the stuff if you come in you have headaches you might end

up in the neuro suite so it's quite interesting how they can do that tumor intervention very high like I said you have the highest rates of HCC in the world you're getting cases they do have y9t available and in fact China just

made their largest acquisition ever with the by what you guys know a company they bought surtex there's a Chinese company now it got bought by China now the interesting is they don't currently have a whole lot of

y9t over there but they just opened up some of their own generators so they can actually start producing the white room 90 and I think you'll see probably a increase in those numbers of y9t cases but to date the number one procedure for

them is taste and they do a lot of them you know like I said on average a community hospital setting you might find 15 or 20 cases a day with three interventionalists so compared to what you guys do there's probably not many

people here unless you're working at a major institution that there's nothing but cancer doing 20 cases a day and I promise you're probably not doing it with only two interventionalists so it's amazing how fast and effective they've

gotten at and below therapy and unfortunately it is necessary because of those elevated HCC levels and like I said when we look at some of these things it's I go over there and I'm looking at the board there are very few

cases for you know PICC lines very few the frosted grams very new bread-and-butter abscess training procedures like we do here in the US they are very it's the prevalence is very simple it's neuro it stays and it's

biopsy and those are some kind of the big three for intervention in China and there it's such a large volume you get to learn a lot when you're over there and CLI PA D even though it's more prevalent in China than it is here

because smoking lifestyle factors certainly westernization of the diet in China which occurred since the 1950s and 60s has led to a lot of McDonald's and and fast food and things that weren't currently available prior to 1950s you

see a lot of PA d but it is very undertreated and certainly talking to some of my colleagues like whom are oh you'll get to see a little bit later on with CLI fighters one of the things that's kind of frustrating for them is

that it is so undertreated it's very common to see amputations in China instead of actually doing pipe in percutaneous intervention they normally like to go too far and you see a lot of amputation certainly above

normal so that's something I think as an interventional initiative when we look at these things coming from a Western perspective it's definitely something we need to pursue a little more aggressively but there it's very little

oh well you're talking about two you know two to three percent you know maybe up to six percent or PID cases very very low levels so equipment in equipment in

China Visconti variable I was very impressed in China at most of the major

cities Shanghai is probably when the most modern cities I've ever been in in the world they have everything in effect it's very efficient everything you pay via we pay they got this little WeChat everything is computerized automated so

when you talk about the equipment when I went into some of the larger hospitals in Beijing and Shanghai they were as advanced as any Hospital I've ever been to in the world Siemens say a fantastic equipment their availability all the

major companies you would find here they have over there as well now I say that in in caveat that there are certainly areas where I've been to that did not have fantastic equipment where tubes were dripping oil on to the patient and

I'm looking at this I'm like what do you want me to do here I literally have LED that looks like he came from 1940's Russia and it probably did there's like a full LED suit and like it looks like Chernobyl so I kind of tried to avoid

doing any intervention there but you know in the in the most part is very impressed with their understanding of radiation protection radiation control and certainly equipment that we're available in those larger cities they

would rival any of the the most modern labs we have here in the US and Europe so just to kind of give you a little thought process and perspective on that and what they're utilizing

and Beijing fresh air here you go so we

talked about lung cancer once again causative factors over in China quite interesting you have the largest pollution air pollution in the world right in the major metropolitan areas of Nanjing Beijing and Shanghai they're an

industrial nation and they don't necessarily hold to the same international Accords we do so you see a predominance of really weird lung abscesses you know lung lesions and nodules that come that you probably

wouldn't be exposed to here in the US because of their carcinogen exposures not just outside of tobacco ism but certainly in the environment that they're around and these are actually pictures I took in Beijing not uncommon

on a day like that that make it look like it's fogged but that's not fog that's an Austria Lucien in fact with one of my colleagues back there Christian we got to go to the Forbidden City and it was

so much pollution that day you could probably see about six feet in front of you so it is quite interesting perspective and as you see everybody walks around with either NIOSH masks or or you know pollution air pollution

masses Commons it's readily accepted so one of those things when we talk about those lung cancers here's a reason to put that into perspective for you so hospital tier systems in China when

we talk about there's three different

levels of hospitals now much like the US you're gonna have major tertiary institutions which your large academic centers you're gonna have your smaller centers which are kind of more of your like mid local community hospitals and

then you're gonna have your very small hospitals and China it's a three tier system you have the primary tier which is defined as less than a hundred beds and that's gonna be very limited access that's normally your holistic

medications you're gonna have a lot of TCM traditional chinese medicine practitioners there and they're more worried about health than they are about intervention if you're in a very small town and you have something that you

need done you're probably not gonna go to a tier a primary tier system hospital you just won't be able to get the intervention you don't start seeing interventional radiology till you get to the second tier and that's not only

between 100 and 500 beds and it's mostly moderate size cities that have these and they have your average intervention they'll do basic things like basic biopsy maybe basic line access you won't see many high-end procedures there and

then you have much larger hospitals with your tertiary care centers and those are the ones that have access to the u.s. products the the European products and well tell you in China it's kind of an interesting model of care when you were

looking for availability to be able to treat your patients those tertiary hospitals very much favored using american-made products and devices as well as your pain made products you can't get that in the secondary

hospitals they're either gonna be all Chinese made products you may get some that were made over in other countries in Asia but they certainly are not gonna be the American made products and the reason for that is any product made

outside of China a patient has to pay for it makes intervention not only frustrating but very complex at times and I'll explain that kind of Maya my quick experience with that as well so

these are the difficulties that I find

in provision of care and when I talk to some Mike in China they definitely commiserate in this what they were telling me that they feel are some of the issues they have you know simonin limits access to

international based medical products it's it's coming up with protectionism they want their products utilized well unfortunately there is a perception that some of these products that were made originally in China and probably not so

much nowadays been in the past we're not exactly up to the same type of you know Quality Assurance levels as US based or European products and that made it very difficult you know guys would go and they would learn in in the Western

world they'd be doing all these different studies and research reading what we're doing over here and then they wouldn't have access to the products or the procedures to take care of their patients the second thing

it's kind of difficult is CFDA which is Chinese version of the FDA they very much limit access and is very hard to get a product from overseas from Europe or to us into China they require in China in-country clinical studies they

require multiple products to actually evaluate so if you want to send us a where we're merit since I have some of my colleagues from Mary here and you wanted to send a product to get evaluated in China they can hold on to

and take up to three years for evaluation they'll last for about 4 000 units to evaluate and then they reverse-engineer them send them back to you and deny your Chinese your CFDA application their masters reverse

engineering so medical device companies are very hesitant sometimes to send their IP products over because international patents are not really covered in Chinese law so they can't knock these products off and and I think

the hardest thing is that patients are required to pay for products that are not made in country so when you're doing intervention I came across this when I was doing intervention and I was very blessed to be able to get credentials

and do intervention over there I would be doing a mather in her case and we had been ovo stents up which I've just got the you know approval here in the US by the FDA two weeks ago they've been using him there for almost two years but the

problem that we had with that is that the patient would have had to pay for them so I'm doing intervention and Manor you have to stent mather no you cannot just balloon it it's not effective and you'll have residual restenosis I had to

stop the procedure get the patients family and explain what was going on and offer them the stent and if they couldn't pay it we got him off the table and we were done and they ended up there I'm bussing their leg off again and

unfortunately that happened you know on one of my patients in his very fresh string is a Western provider clinician who's used to having the ability to do those things you just can't so it's it was definitely a frustrating thing for

me and certainly frustrating for the Chinese physicians and interventional study are there that know what they need to do but don't have access to the products readily or can't make their patients pay for these things because

they can't afford them and also it's kind of coming from a u.s. perspective we're used to single use of products over there there's no such thing as a you know one use disposable they will restore lies things that were not made

to be rese terrorized and as a Western clinician coming over there that's totally against everything we've ever thought about but you just kind of accept that practice and realize it's what's gonna happen so it's it's kind of

interesting I've saw you know IVC filters that were sterilized and we use after being in patients they do what they got to do and so these interesting those are some of the things you need to remember think about considerations

that's different than your ideologies that you were trained in in Western

medicine so very innovative though I will tell you necessity is the mother of all inventions right so if I can't get a hold of these products that I'm reading

about they they come up with some of their own products and some of their own procedures that were very innovative specially in the the world of IO SCI lastik intrahepatic biliary stands are very common over there they were

actually innovated over in China of radionuclide impregnated pillory stents imagine taking y9t shoving them in billary stents and putting them in to treat biliary cancer in atresia they do that quite readily over there we don't

do that here in the US but we're experimenting with it intravascular catheter directed gene therapy actually started in China pre portal vein thrombus to me for transplant liver functionality they do

that very commonly we just consider a very complex procedure over here catheter directed stem cell treatment for focal after mattis lesions they do that instead of doing stents over there and they're all innovated in China so as

I said necessity is the mother all of invention and when you go overseas and you get to work with some of your interventional colleagues who do not have access to what we currently have here in the Western medicine world

you'll be amazed at some of the stuff they've come up with it try to treat their patients so from American

interventional perspective I talk to some of my colleagues you look at this handsome devil right here you guys know

dr. Kumar fantastic guy from Rush University with dr. arseling back there you know Kumar when I asked his opinion he was over in Guangzhou with si our initiative as a visiting professor you know one of the things in his main

for us was that you know even though the government limit some of these things that they want for excess it was amazing to him what they do with what they have you talking about very skilled physicians that we're doing intervention

very complex cases with but out the tools they probably need to do them and certainly when we talked about PA D which is very under-diagnosed and undertreated they're given the tools and the abilities they definitely want to do

more PA d work they just don't have exposure to it and then I talked also to David Trost from Cornell who's also a good friend of mine in ecology that's been overseas and you know his perspective is that you know when you

talk to the Chinese physician the majority of them are very aware of the clinical research going on here in the u.s. they're very well plugged into international societies and know what's going on so when you talk about them

they will speak very eloquently on on the current trials and clinical you know things going on that's you know like I said it was very surprising to me you definitely are dealing with colleagues of equal or even more so international

knowledge than you would imagine so

training of I our physicians in China is a little different there is no formal residency or fellowship current training is a rotational extension during diagnostic radiology

so it's on-the-job training basically your OJT there are some training programs that are being developed as we work closely the CSIR is working with SAR to kind of do something that's more of a model-based

similar to the surf society and how they do their training with a with a board or a qualification test but to date that's not the case there's no medical review board or specific certification for vir interventional radiology and like I said

most most ire physicians are domestically trained they're trained in their local hospitals but you do have some physicians and some of the larger academic institutions they've trained over in the United States I've met a

couple that trained in UCLA you know a couple of them that we have our own visiting professors that go over from si R and do some training with them so they do have a high level of training in those larger cities that that would

rival anything you'd find in our own academic institutions China

interventional research once again China because prior to the 1950s obviously with the Communist revolution and the socialist revolution there it was a kind

of very closed off country but in the past ten years of research true interventional radiology research has increased tenfold because of the opening of domestic borders because of the more internationalization

of China they actually started submitting things into international journals started looking at their IRB processes and I think we will see even more so you're gonna see more and more complex research coming out of China

they've applied more stringent application of IRB standards which has allowed their research to be more acceptable outside of China and the one thing that makes it hard for China to actually produce a high volume of

research is that they get no government funding there's no NIH to be able to provide specific standard funding and there's no medical device company to do funding as well so it's basically academic Hospital making a decision to

do a study and paying for the study that's the one limitation they do have specifically for interventional radiology and producing more relevant and pertinent to academic studies so

average IRA awareness outside the Great

Wall know once again Chinese society of interventional radiology their last meeting had 5 500 attendees the one that slated for this ones they have about a seven thousand that should be coming to this year's so they have a large volume

of people that come to these meetings their IR journals and they have multiple IR journals plus they're very well aware they do read the JV IR they do try to stay aware of what's going on internationally so they are very aware

of the intervention that we have and they certainly as a society are developing a much larger and broader base of trying to plug into the international community and one of the things that SI r has has done very well

they established the global ambassador program sending us trained academics over to work as guest lecturing professors and I'm sure if you guys get a chance they've had a couple sessions here go to those sessions it's fantastic

to see the these people that you look at as ko Elle's speak about their experiences in China and I think you'll find that a lot of its kind of correlate to what I'm telling you here they've been very impressed and in some ways a

little frustrated in the availability of doing what they like to do in teaching what they'd like to teach but it is quite an amazing experience and then

certainly the face of interventional radiology in China is actually a very

good place to be right now you're talking about young physicians that are really getting involved in the field 58% of all Chinese IR physicians are under 40 years of age and status from 2017 you know 40% are under 35 you're talking

about very young doctors who are growing up in the IR you know field and actually you know really building a young base of physicians to carry IR into the next 20 years 41 percent of those physicians also have degrees outside their their

primary medical degree so master's degrees and doctors that's quite high you'll find out here in the US no like I said in China you don't necessarily have a traditional MD you don't you're not an MD actually it's a

bachelor's of Medicine very similar to the European model but a lot of them and majority of them almost have have advanced degrees so you're talking about very intelligent very young very aggressive people trying to carry this

ball and move it forward and try to join the international community of advancing IR and that was very heartwarming for me and made me feel very good to be with those colleagues and realize where the future lies for that kind of tree and

then 72% are bilingual or multilingual which is certainly much better than the u.s. because the Lord knows I can speak anything I can say come by and and Niihau so bottom line is you have very intellectual people that can communicate

very rarely did I have an issue in getting along and communicating with my colleagues in China and in the end we all speak the same universal language which is I are when I'm at a table and I'm scrubbing with those physicians we

didn't have to talk at all okay we knew what we were looking at we knew what needed to be done and we just did it and that's one thing that's always amazing about this field is that we all can speak the same language regardless of

where we come from so my observations

and these are just my personal observations I'm gonna make this quick because you got a great presenter following me and I don't want to push off dr. rustling too much longer but

compassion and smile are universal I didn't need to speak Mandarin to be able to understand what was going on and certainly when I'm at that scrub table and I'm performing procedures on patients we all could smile and laugh

and figure out what was going on very quickly without too much into discussion and so that's the one thing I would always say when you go smiles contagious wherever you are in this world everyone likes to smile

second thing is everything is your usable what you think it should be or not doesn't matter you can reuse it I found that one out betadine is amazing everything is reusable overseas you'll figure that one out quickly informed

healthcare is at a higher level in China and what I mean by that is when you have to have your patient pay for a $2000 stent yeah informed healthcare is amazing because you're gonna pull the patient's family in and you're gonna

talk to them and they're gonna have to make very important decisions about healthcare which is dependent on what type of finances they have and it's kind of sad unfortunately you know I would hope we

can go into a big long debate about US healthcare and everything else but in the end the sheet you put that Stinton if I need to put that stent in and then we'll worry about the finances later on it's

not that way over in there so that can be very frustrating for a clinician he's trying to do what he feels is best or if she feels is best for their patient and they can't you'll find no better MacGyver's than in china and then in

overseas because they will make it work no it's gonna fit no matter what what size fit you have it doesn't matter we'll make it work so it's it is amazing you will find some macgyvering going over there that's

quite fascinating more tase's and i've ever seen in my life you want to learn interventional oncology and you haven't done a taste procedure go to China for a week you're gonna come back and be an expert whether you want to be or not

that's de-facto and certainly the younger I are physicians strong knowledge base of clinically what's going on and excited to plug into their colleagues overseas they want to know what we're doing here in the US

they want to know what they're doing in Europe they want to know about the latest studies and that's exciting to me as a clinician to be able to share that and see that that future there is a strong and bright future for

interventional radiology and when

traveling the dragon these are some things I remember like I said there are more cameras with facial recognition software in China than anywhere else in the world don't embarrass yourself

they'll know you trust me they'll know you at next airport they'll remember you so make sure you don't embarrass yourself I these ideologies and politics divide medicine heals leave your politics at home you're gonna visit

countries that are not necessarily friendly to Western ideology and guess what that's okay I'm not there to talk politics I'm there to talk people and make friends and if you travel abroad you should do that too

it's amazing everybody likes to smile everybody wants their kids to be happy everyone likes a full belly and a roof over their head and to laugh doesn't matter where you are in the world when eating duck tongue watch out for the

bone in the middle of a Christian can tell you about that and yeah I said duck tongue that's right you can eat some strange stuff in China and you're just gonna like it and say thank you and keep on moving listen listen and learn as

much as much as you teach you're gonna learn from these colleagues these international peers are as educated in their own way as you are and you will learn so much from being able to be with them you're not there just to teach

you're there to learn and listen and you'd be wise to take that with you wherever you go and Chinese culture reviewers their elders and place district expectations on the hospitality and etiquette you never leave a table

hungry and sober in most cases and if you don't believe me you can ask Kumar when he gets up here later on about leaving a table over in China it's not gonna happen so

you know Global Opportunities I'm

encouraging you guys to get involved as I are colleagues technologists mid-levels physicians they want you over there and there's many different initiatives sio has a fantastic initiative which focuses on China and

Latin America some of the kos here have had the ability to travel of China and learn you know you're bringing stuff to the table they're to China and they're sharing their knowledge and information with you and knowledge exchange is key

and crucial to advancing interventional radiology now and in the future and then certainly as technologists there's great opportunities rad eight who's quite right outside I just saw them that's a great organization you're gonna get an

opportunity to go to learn to travel a place like Tanzania go to Africa and you got to see my colleague for Carol ma zouri who's a good friend and a mentor talk a little bit about what it's like to be able to perform procedures over

there reach out do something for yourself okay cuz not only when you travel you enrich yourself but you enrich the world around you and in the end that's what I'm gonna leave you with get out learn grow meet

your colleagues overseas have a laugh drink some mal Thai say goodbye thank you very much

any questions at all so it's very diversified you know most physicians as I stated they don't have a residency I

out you know our fellowship so technologists are in most cases more integrated than cases than you would think here in the US you know a lot of fellowship and residency programs as you know when you have a resident fellow

there their Co scrubbing or they're doing the primary case by themselves whereas they're because you don't have that type of formalized residency structure the interventional technologies is doing all the case

within a physician and that's one of those things that one of the initiatives I'm working on is giving some I are technologists over to help train some of these guys show them how we do it here in the US share and kind of give back

and forth information something that's desperately you need to over in China any other questions thank you guys very much you guys made it through congratulations

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