It's been some time since writing an editorial for the journal. Thank you for those of you who reached out to me to ask me to put something on paper for this issue of Seminars. I appreciate your support and confidence in my abilities as an author, Mom.

My tardiness in writing an editorial is due to multiple factors. First, I couldn't think of anything important to say. But, then I figured since that hasn't stopped me in the past, why should it now? Second, I have been inundated with issues related to my primary paying job. But, then I figured I'd put things off so long they became irrelevant, so why should I try to address them now? Turns out that may be my greatest skill as a leader. Finally, I realized that with my ongoing transitions I simply didn't have the time to come up with something meaningful to say in an editorial. But then, I realized that perhaps this period of transition was teaching me some lessons that I could share with my professional community, so here we are.

I am, indeed, in the middle of a transition. A new job in a new city in a new position living in a new house with a new(ish) spouse. Why not—what could go wrong? In reality, I am very excited for this next phase, but instead of dwelling on one person's experience I wanted to focus on the process of transitioning into something new and fresh. I've no doubt that nearly everyone reading this editorial is likely having some sort of transition as well. The transition may be major, such as a job change or birth or death of a loved one. Or perhaps it is something less defining but nearly as important, such as undergoing a promotion or taking on added responsibilities for one's children or spouse. And in some cases, the transition might be so minor that it is going nearly unnoticed until one actively takes stock of his or her own life and recognizes those changes that are taking place barely underneath the surface. Regardless of the number or degree, we are all undergoing transitions on a daily basis, and paying attention to those changes is vital in one particular way—specifically, if we do not pay attention to those incremental and minor readjustments to our lives, we end up losing control of whatever influence we might have in the direction our lives may take. Heavy stuff, it turns out.

There is a very interesting book by William Bridges called “Transitions: Making Sense of Life's Changes; 40th Anniversary Edition” ((2019) Hachette Books, NY, New York). I suppose by definition it is a somewhat dated book, originally published in 1979. Nevertheless, there are still several meaningful lessons in that book, or at least several premises that Bridges brings up that seem particularly timely for me—and, I would posit, for nearly all of us. One of the lessons that struck me as meaningful is the concept that all new directions require three phases: an ending, a transition period, and a new beginning. Per the author, it is impossible to have a new beginning without going through the ending and transition period as well (although they needn't necessarily follow the expected chronological order). Most individuals are not even aware of the transition period and expect in many ways that a new beginning should immediately follow an ending. It is, however, in this transitional period that much of the progress is made and in which a conscious effort might be particularly meaningful. And, almost always, this time of transition is difficult, upsetting, and anxiety provoking. Ignoring it, and/or not allowing oneself to go through it, can provide obstacles to the new beginning that may eventually become insurmountable. As I mentioned earlier, it strikes me that all of us are constantly transitioning; having a playbook as laid out by the author on the best way to change direction is the key to a healthy and meaningful transition. It's a book I would highly recommend.

Taking a step back and out of my own (or your) current transitional phase, I started to notice many parallels between my own pathway and that of our specialty. These constant transitions, endless iterations, define not just us as individuals but also our field in general. The number of transitions I personally have been able to witness over the past nearly three decades in interventional radiology (IR) are too many to enumerate and likely even far too numerous to remember. Clearly—easily—80% of what I do now is brand new compared to being a fellow in 1994–1995. There was no such thing as radiofrequency ablation of any organ, radioembolization, infrageniculate interventions, aortic endografts, sharp venous recanalizations, fibroid embolizations, stent grafts, etc., etc., etc. Imaging was done with cut-film and hyperosmolar contrast agents, and using CT as an imaging tool to guide interventions was relatively novel. Add to that the fact that the procedures that we were doing that were cutting edge at the time (transarterial chemoembolization, inferior vena cava filters, CO2 angiography among others) have all changed so much that they are nearly completely different procedures, either because of the techniques used or because of the disease states or organs in which they are performed. Take transjugular intrahepatic portosystemic shunt (TIPS), for example. TIPS used to be performed with indirect portography via a superior mesenteric artery (SMA) injection with prolonged venous phase imaging (using cut film), bare metal stents placed 1 to 2 mm into the hepatic vein, no embolization of varices even in the setting of acute bleed, and was not yet advocated for in the treatment of hepatic hydrothorax, Budd-Chiari, or as a bridge to transplant. Clearly the ways to do things now are very different than all of us were doing them in the mid-1990s, but like only seeing the growth of your kids through a series of photographs it is only through the lens of the mid-2020s that we recognize how truly far we have come. As I've opined before in this column—that constant evolution and improvement is what makes IR the best field in medicine.

The concept brought up by Bridges regarding paying attention to the transition period is particularly poignant with regard to our professional selves, I think. It is the recognition of two things specifically that translates well to what we do. First, if as physicians we don't recognize the changes going on around us, we cede all right to help determine the path that sets us up for the following transition. I'm trying to wrap my head around the fact that recognizing is not necessarily the same as controlling. There are many things in our professional lives—collectively as a field, as part of a group, or as individuals—that we simply cannot control. But recognizing the changes, accounting for them, and as Bridges writes allowing ourselves to work through that awkward and angst-provoking transition period is the only way to a healthy new beginning. The other day I was talking to our residents about a case on the board and noticed that the patient had an esophageal stent. I asked if they knew when and where stents were first used for esophageal obstructions, and they were surprised to find out that much of the development of that device came out of IR, and the Dotter Institute to be exact. At least that's the way I recall it (and if I recall it incorrectly, don't worry about it; I would be stunned if the residents were actually listening anyway). Regardless, what would have happened if the Dotter had attempted to hang onto esophageal stenting in the 1990s or whenever it was. Or, put differently, what would have been that opportunity cost if their engineers and investigators had tried to continue to wrestle with the endoscopists over what could have ultimately been a losing battle? When I think of all the innovation that has come out of that institution, I shudder to think of what might have been had they not, by letting go of esophageal stenting, had an ending and a transition allowing for a new beginning.

The second translatable concept from Bridges to our field, to me at least, is the notion that one needs to allow oneself that feeling of insecurity, that feeling of uncertainness that comes with a meaningful transition. Perhaps not to the point of buyer's remorse, but when we go through significant professional changes there will inevitably be a period where we are questioning whether we made the right decision. One needn't look too far, however, to translate this concept—discomfort during transitions—back to our own field. How about starting with something as gigantic as being considered a separate medical specialty and all that comes with that? I can guarantee that 99% of the IRs of my generation never thought they would be running a true clinic operation in order to provide the best procedural services. Admittedly, drinking the Kool-Aid took a while (just ask Marx/Kaufman/Laberge et al), and I will admit that there were times when I as an individual IR questioned whether we were really on the right pathway. But here is the driving question for you, the reader—what is the source of the next transition period, the discomfort, that we need to feel now in order to have an ending and new beginning? Like the Dotter and esophageal stenting, what will be our opportunity cost if we continue to let the status quo be the status quo because things are just fine now, thank you very much. What will we miss by not keeping ourselves attendant to potential changes that will move us forward as a field?

It remains incumbent on all of us, whether in academics or private practice, full-time or part-time IRs, more or less experienced, to take stock of where we and the field are and what our next ending will be, because without an ending there can be no transition and without a transition there can be no new beginning. Doing this is not a mere mental exercise; rather, doing this is essential to our continuing to set our own course as individual physicians and as a medical field.

What will we sunset to make way for the next new beginning?

Article published online:
10 July 2024

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