Dr. Hahn's Interview
Dr. Tu's Interview
Dr. David Hahn is an Interventional Radiologist at Evanston Northwestern Healthcare and Assistant Professor of Radiology at Northwestern’s Feinberg School of Medicine. A Chicago native, Dr. Hahn completed his undergraduate studies at Northwestern University and graduated Loyola University's Stritch School of Medicine in 1996. He did a one-year surgical internship at Loyola University Medical Center in Maywood, Illinois and went on to complete his radiology residency at Indiana University Medical Center where he served as Chief Resident in Radiology. In 2001, he returned to Chicago for a one-year fellowship in Interventional Radiology at Northwestern Memorial Hospital and then went on to take a faculty position at Rush University Medical Center in Chicago. He joined Evanston Northwestern Healthcare in 2003 where he helped develop the uterine fibroid embolization program.
Fibroids1: When did you know you wanted to be a doctor?
Dr. Hahn: I knew ever since I was a little kid – after I got through the phase of wanting to be a fireman and policeman. I was also influenced by my father who is a physician as well.
Fibroids1: What attracted you to this particular field?
Dr. Hahn: I always had affinity towards science but I found anatomy and physiology to be my favorite subjects in medical school. When I started medical school I had my sights set on being a surgeon but during my surgical year, I found interventional radiology to be more and more interesting. To me, it’s a field that directly draws from knowledge from these two areas.
Fibroids1: How do you start off creating a treatment plan for your patients with fibroids?
Dr. Hahn: The majority of our patients are referred by their OB/Gyns. A smaller percentage of patients hear about UFE from newspapers, television and word of mouth. Most of our patients are fairly well-informed and trust the recommendations of their primary physicians, which makes it much easier when we see that patient for the first time. Typically, when a patient is referred to me, our clinic nurses set up an initial MRI and clinic appointment. When I meet them for the first time, I am able to show them what their fibroids look like on MRI, talk to them about the procedure and explain the options open to them as well as answer any questions they may have.
Fibroids1: Have your relationships with OB/Gyns changed because of uterine embolization and other procedures?
Dr. Hahn: Absolutely. Being able to work toward a common goal of treating the patient and improving their quality of life gives each specialty a greater understanding of what we both do. If the patient is satisfied by both the choice of procedure and outcome, then both the referring OB/Gyn and interventional radiologist have done a degree of service for their patient.
Fibroids1: How do you determine who is a good candidate for the procedure?
Dr. Hahn: One of the most important things is education. A patient is a good candidate if they are educated about the procedure and informed of all the other options. Technically speaking, uterine fibroid embolization is effective for many different types of fibroids. Both OB/Gyns and interventional radiologists are fortunate to be able to offer new and emerging technologies that result in excellent outcomes. When someone understands all of their reasonable options, I tell them the choice is ultimately up to them.
Fibroids1: Do you find that most of your patients are educated or is there still a knowledge gap?
Dr. Hahn: No there still is a gap. UFE is still relatively new when considering the large array of gynecological procedures. So there is still a quite a bit of education that needs to occur. Even though my patients have access to the Internet and they have good OB/Gyns that are able to answer a lot of their questions, the bulk of the education occurs during their initial consultation.
Fibroids1: How important do you think it is for the patient to be educated before they get to their doctor?
Dr. Hahn: I think that it’s always important for a patient to know something about their condition before they see their physician. With the media and Internet a lot of that information is accessible. Their visit to their physician is more satisfying when they come armed with questions and leave with better overall understanding.
Fibroids1: When you do get a patient with a knowledge gap, what kind of resources do you point them to so they can learn more?
Dr. Hahn: We give them informational pamphlets explaining embolization in layman’s terms and also supply them with CD ROMS with short interactive movie clips. For those with Internet access, we also refer them to the Society of Interventional Radiology’s Web site which is well constructed and very informative. Lastly, we give them our contact information in case they have specific questions directed to either me or our IR staff.
Fibroids1: How would you explain the procedure in laymen terms?
Dr. Hahn: Uterine fibroid embolization is a way of treating the fibroids by cutting off their blood supply so that they slowly shrink and become inactive. We insert a tiny catheter into the groin, find the blood vessels that feed the fibroids and inject tiny particles the size of grains of sand that block the blood vessel and allow the fibroid to lose its blood supply and shrink over time.
Fibroids1: What are those tiny particles made out of?
Dr. Hahn: There are various manufacturers but the vast majority are made out of an inert polymer.
Fibroids1: What kind of success rate is there with this procedure?
Dr. Hahn: The success largely depends on their symptoms, the appearance, size and number of fibroids and the presence of other underlying conditions. Overall the success rate can be 85 to 95 percent.
Fibroids1: Obviously the treatment is quite different from a hysterectomy.
Dr. Hahn: It is a different procedure because it usually involves a one-night hospital stay and most people are able to get back on their feet within a week’s time and go back to their normal activities. They also don’t have a surgical scar. It’s not the same as a hysterectomy and many would rather undergo surgical removal of the uterus altogether. The decision comes down to what is best for the patient and what they want for themselves.
Fibroids1: When someone is not a good candidate for embolization, what other treatments can you offer them?
Dr. Hahn: There is not much else we can offer them, so if a patient is not a good candidate for uterine embolization, by and large we refer them back to their gynecologist. There are however other developing technologies we can offer that appear promising and will likely be available in the near future.
Fibroids1: Is this an emotional issue for any of your patients since it’s connected to fertility?
Dr. Hahn: Most of the women we see are beyond their reproductive years or have finished having families. What I tell patients who are considering having more children is that they should explore that option first and then reconsider uterine fibroid embolization.
Fibroids1: How have you seen the uterine embolization procedure change in the last few years?
Dr. Hahn: It’s changed in a number of ways. Number one: We have refined the technique of the procedure so we are able to treat fibroids more accurately with fewer complications and better overall results. However, the most significant changes are in how we manage the patient before and after the procedure. We have learned a great deal about what the patient can expect in the short term period after embolization. This has helped us better inform them as what they can expect in the post-UFE period. It has also helped us better inform our referring physicians, who are the ones that see these patients first when they begin to have symptoms and explore their options.
Fibroids1: It sounds like this new collaboration between you and OB/Gyn colleagues is actually making things more efficient.
Dr. Hahn: It is. Working together with gynecologists helps create a more global approach to the management of fibroids. The scope of effective treatments now goes far beyond the more traditional surgical methods.
Fibroids1: Do you have a favorite piece of technology that has made your job easier?
Dr. Hahn: Ultrasound. It allows us to be truly “minimally invasive.” Ultrasound doesn’t produce harmful radiation. It’s fast and effective and allows us to visualize the body in real time. With new applications for it such as focused ultrasound, it now encompasses the entire medical spectrum as useful diagnostic, procedural and therapeutic tool.
Fibroids1: What words of advice would you give to interventional radiologists starting out in this field?
Dr. Hahn: Keep an open mind. To remember that interventional radiology is now a field where we need to focus on the entire range of patient’s needs and not just on the procedure itself.
Contact Dr. Hahn
Dr. Frank Tu, MD, is Director of the new Division of Gynecologic Endoscopic Surgery and Female Chronic Pelvic Pain in the Department of Obstetrics and Gynecology at Evanston Northwestern Healthcare. He specializes in minimally invasive, endoscopic techniques and approaches pelvic pain from a multidisciplinary perspective. Dr. Tu's background includes subspecialty fellowship training in laparoscopic surgery and chronic pelvic pain management. He received his medical degree from the University of Alabama, and completed an obstetrics and gynecology residency at Northwestern University and a fellowship program at the University of North Carolina in advanced laparoscopic surgery and pelvic pain management. He conducts clinical studies collaboratively with the Rehabilitation Institute of Chicago's Center for Pain Studies and is an Assistant Professor at the Northwestern University's Feinberg School of Medicine.
Fibroids1: When did you first know you wanted to go into this field?
Dr. Tu: I worked in emergency rooms when I was a college student and found the pace of the clinical environment fascinating. I had a chance to observe some excellent physician role models, and I liked the mix of being able to interact with people as well as use cutting-edge technology – that was probably the reason I got into my field. Of course it evolved from there and I worked in some research laboratories - feel some of the most interesting work we do is the investigational aspect, understanding what the root cause of our patients’ problems.
Fibroids1: When your patients come to you what is their number one concern?
Dr. Tu: Well they want to have their symptoms taken care of, and they want to make certain that whatever they have is not malignant.
Fibroids1: Do you think there is any link between genetics and fibroids?
Dr. Tu: That’s a difficult question to qualify. Fibroids are virtually universal in many demographic groups. I think a more relevant issue would be to try to figure out if women who tend to develop very large fibroids or have significant bleeding from their fibroids have some common genetic heritage. I suspect there will be a link identified - which will help in developing targeted therapy.
Fibroids1: Are you seeing a knowledge gap with your patients with fibroids?
Dr. Tu: In our area, there is a large population of well-educated women that are very savvy consumers. In general women nowadays tend to be well informed about fibroids. But I don’t think that is the case nationwide. Nowadays, people write about in the educational literature about how it is part of our role to be gatekeepers of information and help our patients identify useful and relevant information.
Fibroids1: How do you talk to your patients about fibroids and fertility?
Dr. Tu: You have to balance out the fertility concerns with uterine treatments. My experience is more from referrals for a specialist so I tend to see patients who are much further along in their decision making process. Patients know they have to balance the symptoms they are having against their future desires for fertility. For some patients with overwhelming, unrelenting symptoms, the issue of child-bearing might be outweighed. This really depends on the individual patient. Regardless, patients with uterine bleeding issues often have fertility-sparing alternatives: hysteroscopic and endoscopic myomectomy, to name two.
Fibroids1: How do you develop your treatment plan?
Dr. Tu: I have a referral-based practice so often my primary care colleagues have initiated the counseling. We all discuss with women the whole range of treatment opportunities here at ENH and that certainly includes a multidisciplinary approach. If patients are looking for something more definitive, they often are well-acquainted with the available treatments. At our institution, patients usually see me after they have failed with conventional therapy - sometimes they are looking at a surgical approach - sometimes just for some reassurance that their problem doesn’t necessarily have to be dealt with.
Fibroids1: What would you recommend for a surgical approach?
Dr. Tu: Well, that depends on each patient. There are many effective ways to determine what the root cause is. Certainly if it’s abnormal bleeding then it will be a combination of laboratory work and pelvic imaging studies. If the patient has pain, it becomes a much more complicated situation. We still need to develop a better understanding of differentiating fibroid-related pain from other causes.
Fibroids1: Are you seeing a decline in the number of hysterectomies being done because of alternative methods such as uterine embolization?
Dr. Tu: Not only am I seeing it, but we have data that we will be presenting in November at the national endoscopy conference. The Illinois rate of hysterectomies in the past three to four years shows a fairly substantial drop in the total number of hysterectomies performed. We have seen a drop of 15 percent across the state, likely due to the introduction of these alternative treatments. Savvy patients clearly want these procedures - which can offer shorter hospital stays, a decrease in complications and better patient satisfaction.
Fibroids1: Have you found that the time factor plays an important role in the treatment sought?
Dr. Tu: There is no question that we have a lot of patients who are quite busy. Nevertheless, I think that their first concern in general is that they receive effective treatment the first time. Patients get frustrated when there is a piecemeal approach to their treatment. A careful initial assessment often allows the first treatment to be the right approach.
Fibroids1: Are these new technologies changing a doctor’s job? Have you had to take specialized training?
Dr. Tu: I think it’s very hard for most busy physicians with an established practice to find the time to change their traditional practices. In my endoscopic fellowship, there were fantastic opportunities to develop expertise with these modern surgical methods. One challenge in our field is for educators to find ways to incorporate continuing education for physicians into busy practices. Many of these new technologies, such as the endometrial ablation systems, are designed for rapid skill acquisition.
Fibroids1: Are these new procedures, like uterine embolization, creating more need for collaboration between specialists? Are you working more closely with interventional radiologists?
Dr. Tu: Practices likely vary across institutions. But in general, I think collaborative practices help institutions succeed in delivering better care. We are very fortunate to have a radiology department that is easy to work with - both in aiding in diagnosis, as well determining the optimal therapy for our patients. Case in point - the large fibroid embolization registry maintained by interventional radiologists is being analyzed by a gynecologic researcher from Duke University. That’s certainly the model for collaboration.
Fibroids1: How does the collaboration work at your clinic?
Dr. Tu: There is no question there are advantages being connected to a large hospital network. Our institution has invested in resources for physicians to effectively communicate with each other and get patients’ information to one another. We have an online electronic records system that has proven to be a real asset. Radiology images are available for viewing on computer terminals throughout the hospital system through our secure network multimedia. We are also able to share patient notes with our other colleagues in other departments.
Fibroids1: Do you refer your patients to the Internet as a learning tool if they want to learn more about fibroids and their condition?
Dr. Tu: We certainly give them material in the office that is often off a patient advocacy Web site or commercial Web sites. There are a number of good resources. Within our own electronic framework there are actually internal educational resources available for a number of conditions, so we use that. I think what is particularly effective is the availability of streaming video Internet to visually showcase the procedure and see patients’ interviews who have undergone the procedure. It makes it a lot easier for the patients to understand what they would go through. I suspect in the future that utilization of these tools will be enhanced by displaying outcome data alongside procedures to enhance patient education.
Fibroids1: That must remove some of the mystery and some of the fear associated with the procedure.
Dr. Tu: Absolutely.
Fibroids1: What other new techniques are we going to be seeing in the treatment of fibroids?
Dr. Tu: I think there is always going to be a push to find targeted medical therapies that don’t involve any procedures. Minimizing side effects will be a key component of such alternatives. Right on the horizon is an FDA approved MRI-guided ultrasound ablation technique that delivers targeted energy at a fibroid. There are other techniques for destroying the fibroids locally, and I think we will continue to see miniaturization of technology and more specific targeted treatments.
Fibroids1: Do you think the well-educated patients are creating a demand for these techniques, driving the market?
Dr. Tu: I think the main factor for uptake of new technologies will be demonstration of meaningful benefits for patients, like decreased need for additional procedures and increased patient satisfaction. Those are the things that have driven technology in the past, and fortunately, many academic-industry collaborations work towards that very goal. If we can prove these new techniques are effective, massive demand will shift towards these products.
Fibroids1: Do you have a favorite piece of technology that has made your job easier?
Dr. Tu: Certainly the development of small intra-abdominal morcellating instruments for pelvic endoscopy has dramatically altered the way we deal with large, solid tumors. It’s very difficult to get a large grapefruit-sized specimen out through a dime-sized opening in the abdomen, but these devices help overcome that hurdle nicely.
Fibroids1: What is your biggest challenge when treating your patients with fibroids?
Dr. Tu: Perhaps the biggest challenge we face as gynecologists is pelvic pain disorders. They are much more common than recognized and frequently are a source of diagnostic confusion. Because fibroids are so common among women, there is a natural instinct to treat fibroids as the root cause of pain disorders. Truthfully, there are numerous contributing factors to pain in the pelvic area besides fibroids. I think the real challenge is trying to unearth what the actual causes are without doing the flip-side of under treating relevant fibroids.
Fibroids1: What future changes would you like to see in your field?
Dr. Tu: I think women’s health, like most fields will continue to benefit from investigation into the biology of these disorders. The most exciting approaches on the horizon have derived from a better understanding of why some people develop conditions like fibroids in the first place. Determining the epidemiology of a condition often helps us to really determine if a procedure is necessary or not. At our institution, where there are researchers heavily involved in developing quality life measures, there is a real push to objectively characterize patients’ symptoms in ways that allow comparison between different cases. Such research allows us to uniformly determine the impact of medical interventions. The fibroid registry I mentioned is one example of tools that our medical system needs to incorporate so we continue to offer optimal care for women.