Recently, Fibroids1 had the privilege of interviewing Dr. Ducksoo Kim and Dr. Stephen Baer, two accomplished physicians in their own right who have joined up to form a uniquely effective team. Six years ago, Dr. Kim and Dr. Baer began working together to perform a treatment for fibroids known as uterine fibroid embolization. Since 1996, when they became a team, they have performed this remarkably effective procedure more than five hundred times. They currently receive referrals from all over the Northeast. In this interview, they discuss the extraordinary potential of the procedure, as well as the value of their own unique teamwork.
Contact Dr. Kim
Contact Dr. Baer
Fibroids1: Dr. Kim, how did you get started in interventional radiology?
Dr. Kim: I did a residency in diagnostic radiology —chest x-rays, CT scans, MRIs — but I wanted to be more involved in patient care, and interventional radiology is the only subspecialty in which I could be a clinician and be taking care of patients. I spent two years preparing in cardiovascular interventional radiology at Stanford University , from 1981-1983. Then I came to Beth Israel, Boston, and became the Director of Interventional Radiology and an Associate Professor at Harvard Medical School. While working there, I met Dr. Baer. I’ve performed 20,000 interventional procedures since the 1980s.
Fibroids1: And, Dr. Baer, how did you get started in your specialty, obstetrics and gynecology?
Dr. Baer: I started out as an engineer, was a naval officer, then went to medical school. I did an internship in internal medicine, but after that year I embarked on a course of study and residency in ob-gyn at Beth Israel Hospital. There I functioned both as an ob-gyn and in administration. I also worked for a couple of years at the Harvard School of Public Health, in health policy management.
I became interested in interventional radiology quite by accident in the 1990s. I had followed many patients for uterine fibroids. At that point, the main avenue for symptomatic fibroids was a surgical approach. I had one patient, an architect, whom I had followed for many years. Around 1996 or so, she was at the point where we needed to do something - her anemia was getting worse. There was only one small problem: she had a phobia of surgery.
Because of this, and with her background in computers, she researched a new procedure on the Internet that was being done in Paris, as well on the West Coast, at UCLA. I decided that I would try to find somebody in the Boston area who might be able to do this procedure for her. Much to my surprise, there wasn’t anybody in the Northeast doing this procedure; the closest place was Philadelphia. I decided that I would try to find someone in the area to do the procedure, and came up with a colleague of mine, Dr. Ducksoo Kim, who is a superb interventional radiologist originally from the West Coast. At that time, he was Chief of Interventional Radiology at Beth Israel hospital. He agreed that we would treat this patient together, and the patient agreed. We performed the procedure and it was very successful. The patient’s symptoms abated and her bleeding stopped, and we decided this was something we were going to make available to patients in this region. From that point on we worked together as a team. I’ve received the benefits of tremendous training with Dr. Kim, and as far as I know we are the only truly hybrid team of a radiologist and an ob-gyn performing this procedure.
Fibroids1: Dr. Kim, can you tell us more about this first case?
Dr. Kim: Yes. She was a very interesting woman. Gynecologists recommend hysterectomies, but she didn’t want a hysterectomy; so she went to the Internet. She found information about a new procedure, uterine fibroid embolization, so she asked Dr. Baer about it. Dr. Baer had never heard anything about that kind of procedure, so he came to me and asked whether it (UFE) could be done.
This was not really new; we used to do uterine artery embolization for other conditions. Sometimes patients have a lot of bleeding problems after surgery, like a hysterectomy, so we go into the uterine artery and embolize. Sometimes, during the delivery of babies, there is placenta remnant that they try to deliver, but still the patient is bleeding because the uterus doesn’t contract. In that case, we go into the uterine artery and we plug it with little particles. Another situation is cancer in the uterus, and the patient is a poor surgical candidate. In those cases, the clinicians ask us to go in and plug the uterine artery. So this is not new; but it is new in the case of fibroids. Together we did the first case in New England, in 1997, six years ago. Since then we have done the procedure for more than 500 patients together, many more than anyone else in this area.
Fibroids1: Do people travel here for you to do the procedure? From how far?
Dr. Kim: Sometimes we get patients from New Hampshire, Connecticut, almost the entire state of Massachusetts.
Dr. Baer: Our referral area extends over the Northeast. There are very few people, at least in the U.S., who have much more experience, because the procedure started in 1994.
The procedure started in Paris, with a doctor named Dr. Ravina, a gynecologist who primarily performed fibroid surgery. As the anecdotal story goes, the French were having a bit of a problem with their national blood supply at that time. People were afraid to have any kind of surgery that might require a transfusion. Since that was a possibility with fibroids, women were afraid to have surgery requiring a transfusion. He decided that if he sent the patient to an interventional radiologist first, to block the blood supply to the fibroid, his surgery would be relatively bloodless. The unknown feature to him was that while they were recovering from that procedure and getting ready for the surgical procedure, the fibroids shrank and their symptoms went away. That was the beginning of this procedure. It caught on in Europe extensively, and then more slowly in the U.S. Dr. Ravina had discovered, quite by accident, that this was not in addition to surgery but rather an alternative to surgery.
Fibroids1: Can you give our readers an explanation of uterine fibroids in layperson’s terms, for readers who might not know what they are?
Dr. Kim: A fibroid is a benign tumor, not cancerous at all. A lot of women have them without knowing. Sometimes they’re silent, they don’t give you any problems. About 20-30% of women have fibroid tumors. There’s some genetic relation, usually the patient’s mother had the same problem. Some common problems are heavy periods, painful periods, urinary frequency (every thirty minutes or so), painful intercourse, infertility, miscarriage, constipation, back pain, and abdominal distension (bloating).
Dr. Baer: Approximately 25% of women have fibroids. It’s a slightly higher percentage in the black population, but it exists among all races. So this indeed is a very common condition. It does not by itself lead to cancer; the incidence of cancer is exceedingly low, less than one in 1,000. If the physician thought it was cancer, then they need to perform surgery. But the risk of cancer is so low that ordinarily asymptomatic women do not need to be operated on just because they have fibroids.
Fibroids1: An alternative to uterine fibroid embolization is a hysterectomy, which is quite a bit more invasive. Is that correct?
Dr. Kim: Hysterectomy is taking the whole uterus out. Myomectomy, another type of surgery, means taking only the tumor, and then sewing back the uterus. Hysterectomy is a complete, definitive kind of surgery. You don’t have any more fibroids, but it’s a risky procedure. There may be a lot of bleeding, complications, infections, and there’s a risk of mortality. Myomectomy has similar risks.
Fibroids1: Could you give our readers a little more of the idea of the contrast between these procedures and uterine fibroid embolization, and why you prefer UFE?
Dr. Baer: First, the UFE procedure takes approximately 25 to 30 minutes. We’ve gotten it down to that from the original three or three-and-a-half hours’ time. Secondly, it’s done under IV sedation, at least in our practice, with the patient awake, so the risk of a general anesthetic is absent. In good hands, [the risk of anesthesia] is relatively small, but there are patients who die just from anesthesia. Thirdly, there’s no cutting. There’s a puncture, as when one starts an IV, except it’s an arterial puncture, and given the size of the catheter, it doesn’t even need to be closed. In a week’s time the patient can’t even find the mark. That’s another major advantage. The recovery time varies from patient to patient. There’s always a range but it goes anywhere from two to three days up to two weeks. It’s not always easy to predict which category the patient will fall into. By contrast, surgery recovery time is anywhere from four to six weeks. So that, in and of itself, is a major advantage.
Fibroids1: What are the other advantages that a patient can receive from this procedure?
Dr. Kim: With hysterectomy or myomectomy you have to stay in the hospital for three days, you need general anesthesia, and the hospitalization is longer: three days, versus less than 24 hours for embolization. The recuperation for uterine fibroid embolization is only five days or so. With either hysterectomy or myomectomy, recuperation takes about six weeks. The patient has to stay at home, she will have a big scar, and once the uterus is removed, there is a big space. The uterus is supposed to fill the space below the pelvis: if the uterus is removed, there is an empty space and there is no support for the bladder. Some people have urination problems, called "incontinence," when they cough or sneeze. Many women have that problem after hysterectomy.
Fibroids1: What gaps would you say currently exist in what patients know about this treatment and about fibroids in general?
Dr. Baer: Well, I think many years ago the knowledge that patients received about fibroids was mainly from their gynecologist, and gynecologists are trained to operate on fibroids when they start to become symptomatic. Interventional radiology is not in the ob-gyn’s skill set. There have been shows - like the Oprah Winfrey show, combined with press coverage by CNN, The New York Times, as well as other newspapers, plus the web, where it was popularized about five or six years ago. I think the Internet has been a boon of information for people, and has made medical information quite accessible to the average person. And I think that it has led to chat rooms and the ability of patients to find out from other sources about new innovative procedures and techniques.
Fibroids1: How would you rate the awareness of this procedure among ob-gyn? Would you like to see that group of specialists become more familiar with it?
Dr. Baer: Yes. I think that both ob-gyn doctors and doctors of internal medicine, whom we also refer to as primary care physicians, who see female patients - all of those people encounter patients with problems associated with fibroids, and a broadening of the education of what’s available would be very helpful. The gynecologist may regard this procedure as an infringement on their bailiwick, but I think [that concern] is probably ill-founded. The number of people who have fibroids, as we mentioned before, is quite large. Only a very small subset of people who are severely affected by a combination of symptoms will seek help. Either one or all of the following — heavy or prolonged bleeding, anemia associated with that, what we refer to as dysmenorrhea or painful bleeding or periods, pelvic pressure or pain, problems relating to intercourse — all of those are symptoms that often will make the patient seek help. However, there are many patients who are quite symptomatic but who don’t even go to the doctor because they are worried about having to go through that surgical procedure. We see a lot of those patients as well. Let me also add that there are approximately 200-300,000 hysterectomies done a year in the U.S. It may be the most common operation on women aside from C-section, which is done for a different purpose. I think that affording patients an alternative to a major surgical procedure is something that everybody should want.
Fibroids1: If I were a patient with fibroids, where should I go for more information about the condition? What resources would you recommend?
Dr. Baer: First, your doctor or nurse practitioner. Second, the Internet has quite a bit of information already, but in the coming months there will be several new websites available for women to find out about treatment modalities.
Fibroids1: Dr. Kim, how good do think patient awareness is of this treatment?
Dr. Kim: Not many people know about it because many primary care physicians don’t know much about this procedure as an alternative to hysterectomy or myomectomy. Some gynecologists have a negative view of it because of "turf" issues. They feel that radiologists are invading their territory. They don’t voluntarily recommend it, and when a patient asks, many times they don’t say good things. They say "I don’t know much. This is new, experimental." The patient doesn’t get full information from her doctor.
A lot of patients are getting information through the Internet or from friends who have had this procedure. A lot of my patients are referred by my previous patients. They talk when they go back to work — and then their friends say "Oh, I want that, I have the same problems, I might have to go see Dr. Kim or Dr. Baer." That’s the way we get a lot of patients. But now we are changing our tactics. We want to market this because it’s very beneficial. We have a good track record, and it’s not experimental anymore. We’ve performed this procedure for seven years and we have a high satisfaction rate, a high success rate, so we are comfortable about going out and marketing this procedure aggressively.
Fibroids1: What do you think is a solution for the problem that other physicians are not referring enough patients?
Dr. Kim: Gynecologists are slowly becoming more open-minded. Hysterectomy is the first or second most common surgery they perform. They have two hundred thousand hysterectomy patients. I think that’s the main issue. But with Dr. Baer and I doing this, we share whatever reimbursement we receive. So there’s no issue about any turf-related kind of things; there are no conflict of interest issues. That’s why it’s unique; we only consider the patient. We perform it [uterine fibroid embolization] and in the end the patient becomes the winner.
We have a very high success rate. Better than most cases. There are two different [kinds of success rates]. Our technical success rate, meaning our rates of achieving the job, is more than 99%. But that doesn’t mean that every single patient of that 99% has symptomatic relief. Often they don’t, in spite of our technical success. There’s the other one, clinical success, which means success...
Dr. Baer: ...from the patient’s perspective.
Dr. Kim: Yes. The doctor’s perspective is technical success, not having complications. We haven’t had any major complications. In six years, our clinical success is about 90%, which is better than most places. In other places, only the radiologist is doing it. We are a unique team; we have unique teamwork.
Fibroids1: Do you think this team model would work for other physicians?
Dr. Baer: One of the things that Dr. Kim and I hope we can accomplish in the near future is to encourage other ob-gyns and interventional radiologists to form teams. The team approach has worked very well for us. And I believe this, aside from our skills, is the reason for our success. As I think I may have mentioned, we have performed more procedures than most of the other practices in the Northeast region. Gynecologists in general are not happy about referring patients to interventional radiologists who do the procedure, but then if the patient develops problems, interventional radiologists are generally not available to help patients. They are, in some cases, but not in most. In that case, the gynecologist feels put upon to care for the problems that might be associated with the procedure but they were not involved in the process itself. I think sharing the patient, the fees and everything that goes along with that would go a long way both for sparking the interest of both doctors and giving the patient the best possible care that one can.
Dr. Kim: Physicians can be like tigers, they can be independent. That’s why they wanted to be doctors. They don’t have to be hired, don’t have to work for someone else. They don’t have to work with other people. You can practice by yourself, you’ll be fine. So when there are different specialties [involved in a case] they don’t all mix well together.
But, for the sake of the patient, we always have to talk about whether someone in another specialty might know something we don’t know. Otherwise, we can’t do the best job because of a lack of knowledge. It’s like government. The President needs a lot of different secretaries, Defense, Labor; this is kind of the same thing. We are trying to provide the best care, so we always talk about what is the best for each patient. Maybe hysterectomy, maybe myomectomy, maybe uterine fibroid embolization. We always weigh the benefits and the risks ofthe alternatives, because it doesn’t matter at this point. We are working together.
Contact Dr. Kim
Contact Dr. Baer