An Interview with Takao Ohki, MD, PhD
EVT's Chief vascular surgeon on his move to Japan, his new position in the US, and the current state of the art in Japan.
In our last interview with you, our first question pertained to why you moved from Japan to the US to practice vascular surgery. Recently, you relocated to Japan and accepted a new position in the US, as well as another in Japan. What made you decide to practice in Japan again?
This was a very difficult decision to make. In order to answer the question, I need to clarify some of the details that were related to this decision. First, the deal that I was given in Japan was (1) the position of Professor and Chief of the Department of Vascular Surgery at Jikei University in Tokyo, Japan, and (2) the pre-tax annual salary was $65,000, which was roughly 1/10 of what I was making in New York. Second, Jikei University is the place where I spent 6 years as a medical student and also where I did my surgical training. Thus, I know many people at Jikei, from the Dean to the janitors. It is an institution that occupies a big place in my heart and was in big trouble at the time I made my decision due to a series of scandals involving medical errors and accidents. Finally, the endovascular arena in Japan lags significantly compared to the US and the EU. For example, at the time I made the decision to return to Japan, there was no approved stent graft for abdominal aortic aneurysms or thoracic aneurysms, although the Cook Zenith did win approval 1 month after I arrived (almost as if it were waiting for me). This is 7 years after the first stent graft was approved by the FDA in the US. Furthermore, in Japan, there are no approved carotid stents, atherectomy catheters, cryo-balloons, filter protection devices, or newer self-expandable and balloon-expandable stents, etc.
My life in New York was as good as it gets. I was the professor and chief of the prestigious division of vascular surgery at Montefiore/Albert Einstein College of Medicine, whose predecessors include Henry Haimovici and Frank Veith, two giants in our field. As the chief of the service, I was given the authority, freedom, and the funding to run the division as I wished. Also, I was supported by great partners, nurses, secretaries, physician assistants, fellows, and technicians. I had nothing to complain about. However, things in New York were too stable and I guess I was hungry for excitement and passion.
When this offer from my home country and mother institution came along, I felt excitement, something that I had not felt recently in New York. I had the passion to contribute to the field of endovascular intervention in Japan, as well as to help the institution from which I graduated. I had trained more than seven vascular fellows and numerous surgical residents in the US, all of whom have a special place in my heart. I am proud of the fact that six of those seven fellows have become the chief of the endovascular program at their new institution. I have also operated on more than 3,000 patients in the US. I felt it was time to train Japanese doctors and treat Japanese patients.
I came to the US 11 years ago. Initially, I was not paid a salary. My first child (Showhey) was born under Medicaid. It was a rough time. During the 11 years I stayed in New York, many good things as well as bitter things happened, but I was able to accomplish many things, and I am truly blessed. I started working as a physician in 1987 in Japan. Since then, I have experienced the highs and lows that life has to offer. For example, during the last 19 years, my annual income has fluctuated between zero to close to one million dollars. One thing I realized after going through the peaks and valleys of life was the fact that my family's and my happiness (how often we smiled, how blessed we felt) had almost nothing to do with income.
Because I was convinced from my experience that income (as long as I had enough to send my kids to a decent school) had almost nothing to do with my happiness, I made the decision to follow my passion, to listen to my soul, and remove the financials from the equation. It was a tough decision to make but after all, listening to one's soul was an easy thing to do.
You have also taken on a new role at North Shore LIJ Health System: Professor of Vascular Surgery and Director of the International Program of Excellence in Vascular Surgery. What can you tell us about your role at North Shore, as well as the goals of the International Program?
North Shore/Long Island Jewish (LIJ) Health system (www.northshorelij.com) consists of 15 different hospitals and is one of the largest health care system in New York City. Both North Shore and LIJ hospitals boast cutting-edge infrastructure, including state-of-the-art catheterization labs, as well as operating rooms. Its cardiology, liver surgery, and cardiac surgery services are among the finest in the country.
I am attached to many of my patients, and they may need further care in the future. There was an overwhelming number of requests, not only from my patients but also from referring doctors, for me to continue to practice in New York. Therefore, I initially planned to maintain a part-time position at Montefiore so that I could continue to see and treat these patients. However, things did not work out at Montefiore. Dr. Ravikumar is the Chairman of Surgery at North Shore/LIJ, and he used to be the Chairman of Surgery at Montefiore. Thus, I had known him very well. He was the one who promoted me to the rank of full professor at Albert Einstein College of Medicine (AECOM) at a record age. He called me up and asked me if I was willing to do what I had planned to do at Montefiore at North Shore/LIJ. It was an easy decision for me. My goals are to continue to see my patients but also to foster training, education, and international relationships between North Shore/LIJ and other countries where they may need help. In Japan, the field of endovascular therapy needs help from the US, and we thought that developing a program between the two countries would be a very good thing to do. We plan to exchange residents and fellows between the two countries. More importantly, we are aiming at conducting a global clinical trial in which protocols are submitted to the FDA and its Japanese counterpart (MHLW/PMDA) simultaneously; trials conducted in both countries and ultimately medical devices will be approved simultaneously. This will be a significant plus for Japan, a country that lagged 7 years in approving the AAA stent graft.
How will your time be divided between your new practices in Tokyo and Long Island?
I plan to devote 3 weeks at Jikei and 1 week out of each month at North Shore/LIJ. I already have 3 million frequent flyer miles. You can imagine how quickly I will accumulate more. My goal is to accumulate 10 million miles and to fly free for the rest of my life.
What can you tell us about Jikei University School of Medicine?
Jikei University School of Medicine is in the heart of Tokyo, only 3 blocks away from Tokyo Tower. It is located in the best area in Tokyo. Jikei University was founded in 1881 and is the oldest private medical school in Japan. The famous credo written by our founder Dr. Kanehiro Takagi is still practiced today; "Treat the patient not the disease." This teaching carries increasing weight especially in the world of super-specialization and high-tech medicine. Although I was not given a special deal in terms of salary, Jikei University is building a brand new cath-lab/OR for my department. This room will be equipped with the state-of-the-art flat panel C-arm (GE Innova 3100). We have also purchased the brand new OEC 9900MD. We also connected the cath-lab/OR and the 300-person auditorium with a fiber-optic cable for live surgery transmission and educational purposes. Jikei has great infrastructure, and it will be a great springboard for me to develop a vascular/endovascular program. Furthermore, I am surrounded by colleagues and classmates that I have missed for 12 years while I was away.
How would you compare the current state of endovascular therapy in Japan to that of the US? What are the biggest differences you have seen?
As I mentioned earlier, access to new technology is the biggest difference. Also, in Japan, vascular surgery is performed within the department of cardiovascular surgery as opposed to department of vascular surgery as it is in the US. Under this setting, cardiac surgery will always be the mainstream, and vascular surgery or vascular surgeons tend to be treated as second-class citizens. Until we recognize the role of vascular surgery and endovascular intervention and give it some level of independence, its quality will not be the same as in the US or EU. One way to evaluate the maturity of any given field is to look at the number of procedures performed. In the US, we perform roughly 200,000 carotid endarterectomies (CEAs) each year, whereas in Japan, only 1,500 are performed. In addition, most of these are performed by neurosurgeons. The population of Japan is half that of the US, and atherosclerosis is not as prevalent in Japan (the number of PTCAs is approximately one third per capita compared to the US). Therefore, we should expect at least 35,000 CEAs as opposed to 1,500. One of my goals in Japan is to increase the public awareness of vascular disease and then treat them well. By the way, stroke is the third leading cause of death in Japan; the same as it is in the US. There is a lot to do in Japan.
How did your wife and children respond to the news of moving back to Japan?
They hated it. My son and daughter were both born in New York City and both are US citizens. Also, they attended one of the finest private schools in the New York area. They had no complaints about living in New York. They feel that they are victims of my passion. Japan is still a tough environment for both kids and women. However, one day, I am hopeful that they will understand my vision and ideas and why I made this somewhat crazy move.
What are your long-term goals for your new practice in Tokyo, as well as your overall role in the Japanese medical community?
What would you like to see accomplished in the next 10 years? Salaries for physicians and nurses are very low in Japan compared to most developed countries. In addition, as long as one is an employee of a hospital or full-time faculty, one's productivity and specialty have nothing to do with the salary. For example, a pathologist who does one autopsy a month has the same salary as a vascular surgeon who does 500 vascular procedures each year. This is not a fair system because the risk one is taking, the intensity of the training, and how busy one actually is are radically different between each individual, as well as different specialties. In an academic setting, the average salary of a staff surgeon or a staff cardiologist (which is equal to a pathologist and other specialty) is estimated to be about $45,000. They need to moonlight once a week to make up for the deficiencies. I would like to reform this payment system and try to increase the salary of the people that makes it happen.
Also, I would like to contribute to speeding up the approval process of medical devices and drugs. There are a number of reasons why it takes more than three times longer to win approval in Japan compared with the US. One reason is related to the fact that hospitals in Japan are not equipped to do clinical trials. The vast majority of teaching hospitals do not possess a clinical research coordinator (CRC) and all the work, including filling the case report form (CRF) is performed by the physicians who are already overworked. At Jikei, we have hired seven CRCs to perform clinical trials efficiently and properly.
In addition, obviously I would like to develop the best vascular program in the country, train lots of vascular physicians, and contribute to Jikei University and the country. As the first step, I launched the First Japan Endovascular Symposium (www.jikeisurgery.jp) in August. Since I am the only one who does advanced endovascular procedures at Jikei at this point in time, I personally performed 15 live cases over the 2-day period, including two TAA and three AAA stenting procedures. Despite the fact that we announced this symposium very late, 408 people participated, and it was quite successful.
I would like to take this opportunity to say thank you to all my friends in the US who helped me during the rainy days. I had a great time and could not ask for more. The United States of America is a great country, and my family and I will definitely miss it. My e-mail account (email@example.com) will not change, and my new contact information is Professor and Chief, Department of Vascular Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, Japan, 105-8461. Phone: +81-3-3433-1111 ex. 3400, fax: +81-3-5472-4140. My new contact in the US for both friends as well as patients is North Shore LIJ Health System, Albert Einstein College of Medicine, 1999 Marcus Avenue, Lake Success, NY 11043. Phone: (516) 233-3600, fax: (516) 233-3605. If any of my friends plan to visit Tokyo, please send me an e-mail. You can expect a red carpet at the Narita airport. Sayonara!