Midwestern Work Ethic: An interview with Michael C. Dalsing, MD

Hailing from a large family rooted in a small Wisconsin town, Dr. Michael C. Dalsing has forged a career that established him as one of the early investigators in the research of percutaneous venous valve placement and made him arguably the youngest person to become a division chief of vascular surgery. As the first director of the Division of Vascular Surgery in the Indiana University School of Medicine Department of Surgery in 1987, he was instrumental in the growth of the vascular program, initiating the Independent Vascular Surgery Training Program and Integrated Vascular Surgery Training Program. He has also traveled the world, delivering over 200 medical presentations, has over 130 peer-reviewed articles, and 35 book chapters.

When you think about work ethic, it conjures thoughts of the heartland, where work ethic is not so much appreciated as it is expected. Described by author John Kreicbergs in his article "The Quiet Curse of the Midwestern Work Ethic," “It’s an unwaveringly pragmatic and dogmatic belief that hard work and perseverance rooted in quiet humility pays off in the long run.” After having the pleasure of interviewing Dalsing, I can think of no more an apt description to embody his spirit.

VM: I understand you come from farm country in Wisconsin, from a large family with six siblings. How did you transition from growing up in a rural area to pursuing medicine?

MD: Everyone who I knew growing up (in a small town in Wisconsin) was basically either a farmer or worked at John Deere Tractor Factory. Those were the two occupations, and I never had an interest in either of them, although I did like the physical work. I liked the work part of it but I didn’t want to make a living doing it.

I was one of the first in my family to go to college, and that opportunity was given to me by my older brother and two older sisters. It wasn’t the norm to go to college where I grew up, and they were the ones who convinced my parents that this was something people should do. My older brother went into the military and got into computers before they were a big part of our daily life, and my older sisters trained for careers in the medical field (nursing and pathology), which required advanced training, so they saw a different life than my mom and dad did. My parents were from the WWII generation where surviving was good and having enough on the table was good, and you were doing pretty well if those two things happened. My older siblings brought a different perspective to my parents.

I guess I had the aptitude and my grades were good enough, and my older brother and sisters pushed me to go further. My older siblings paved the way for me, and after me, all of my younger siblings went to college. It was a big switch from the older ones to my younger siblings.

Whenever you get to do things, it’s usually a privilege that people have given you--an opportunity to take on a task and see if you can do it. Working real hard is part of it, but a lot of it has to do with fate and where you are at a certain time, and the turns that life takes. I think I’ve been privileged in many ways to have been given the opportunity.

"I must admit that I was much better at anatomic studies than I was in physiologic studies, so even early on, my bend was toward surgery. And my personality isn’t one that likes to deal with chronic issues. I would rather have something that I take care of and see the result quickly—one way or another. It was more of an outlook on life and maybe a personality bend in not being able to wait long-term for gratification; it was more of a situation of ‘Can I do something and make it work, and at least see how I did?’"

VM: Tell us about your college experience.

MD: I ended up at St. Mary’s College in Minnesota on a full scholarship, because that is what I needed to have to be able to attend college with seven kids in our family. It’s a small college with no football, but they had a small ski hill on campus. They had hockey, but I’m not a hockey fan at all. (laughs)

Toward the end of my time at St. Mary’s, I was living in a house with seven other guys, and half of them were taking their MCATs. I was a biology major. I thought I was going to go into molecular biology. At that time, molecular biology was beginning to discover how cells worked, and it was very interesting. But as fate would have it, I was encouraged to take the MCAT at the same time as some of my college roommates. Thankfully I took the MCAT and was able to attend medical school, because my talents were much more along the lines of technical skills than basic science skills.

VM: What were your influences that led you to pursue vascular surgery?

MD: After St. Mary’s I went to Marquette, which is now the Medical College of Wisconsin. Like everybody else, I had people who influenced me, people who you see that you think do a good job, are hard working and have a lifestyle that you think you see yourself doing. For me, those people were Jonathan Towne and Vic Bernhard. They were vascular surgeons; they seemed like they had a special interest in what they did and a special long-term rapport with their patients.

I must admit that I was much better at anatomic studies than I was in physiologic studies, so even early on, my bend was toward surgery. And my personality isn’t one that likes to deal with chronic issues. I would rather have something that I take care of and see the result quickly—one way or another. It was more of an outlook on life and maybe a personality bend in not being able to wait long-term for gratification; it was more of a situation of "Can I do something and make it work, and at least see how I did?" (chuckles)

VM: How did that transition into treating veins?

MD: I went to Indiana for general surgery training, and then went to Northwestern University where I completed a vascular surgery fellowship under Jimmy Yao, John Bergan, and Bill Flinn. They had a real interest in research, how things work, and how you can make them better. Drs. Bergan and Yao were influential in my membership in the then newly-formed American Venous Forum. My first interest in venous disease was because I wanted to make a venous valve that worked and that was a constructed valve using synthetics or something other than a native valve. That was a real clinical nemesis at the time—and may still be—because no one has yet completely solved the problem. It seemed like a real challenge.

I did some early experiments with animals and had some success. There was a commercial company that had a cryopreserved tissue. We used the harvested veins as arterial grafts, but I thought that if you turned them around, they would work as a vein valve substitute because they contained valves as one would expect. We had some animal work that suggested it could function and then took that work using cryopreserved allografts as venous valve replacements into humans. The transplants generally functioned early, but unfortunately the valves would become fibrotic and not function long-term.

Over a period of time, they would degenerate. So, all that early animal and clinical experience did not pan out to answer the question that I wanted to answer. But as a result, I became involved in venous disease treatment and venous research and through the venous societies with surgeons like Bob Kistner, who was the valve guru at the time, and who became a valued mentor, colleague and friend.

Presenting some of my early papers during that time, it was really refreshing to see people who were open to new ideas and trying things that would help their patients. It was that early work doing animal experiments, and my early clinical experience in venous disease, that really got me started down that road and is how I became interested and remain interested in venous disease.

"I do keep my ear to the ground on people who are looking into end-stage venous disease, and I try to keep up with what people are doing now. There are some exciting things yet to come, and I don’t think we’ve even thought of the things that could be done, just because we don’t yet have the technology or expertise."

VM: Where do you see the future of percutaneous placement going forward in venous disease?

MD: I still think that this is something that will happen. It will happen because we will either find new bio materials that don’t thrombose in the body or synthetics with similar resistance to clotting. There’s been some interesting clinical work by a doctor named Oscar Maleti in Italy, where he makes venous valves with a micro knife—and they actually work.

I think with some percutaneous tweaks on that knowledge, or maybe the engineering of a novel valve from the person’s own smooth muscle cells and endothelial cells in a test tube, which could be placed on a stent, we may have a solution. Maybe there are things down the road that we simply do not know of yet that can be used to solve the problem. You know, we never thought we could fix aneurysms like we are fixing them now, where you place a graft and open it up inside and actually fix the aneurysm.

I think the venous valve world will eventually be realized. It’s kind of the last frontier. We can stent things open, but we can’t manufacture a percutaneous functioning valve yet that works for a long period of time. There are some very expert doctors like Drs. Kistner, Raju, Tripathi, Maleti and others who have mastered ways to fix deep vein valves for patients who need this approach by an open operation, but this may not work on all such patients and has its risks.

Those who lack a normal valve that can be repaired do worse than those with such a valve. Having a recurrent ulcer on your leg for years and years isn’t exactly a great quality of life. So I think people are still investigating better ways, and I think after we take care of all obstruction and we’ve removed all the superficial vein reflux, there will be a group of patients who need a valve that must work. And I think that as the population of the world gets older, it’s going to become more of an issue.

I do keep my ear to the ground on people who are looking into end-stage venous disease, and I try to keep up with what people are doing now. There are some exciting things yet to come, and I don’t think we’ve even thought of the things that could be done, just because we don’t yet have the technology or expertise. I think we will see a venous valve that works in the next decade, or even sooner.

VM: What was it like to be selected as the first Director of Vascular Surgery at Indiana University?

MD: That was not an expectation! (laughs) I had been offered a job before I went to Northwestern to come back and become a partner with a doctor named Russ Dilly. After I was here for a period of time, there was a change of leadership and Russ went into private practice. About two and a half years after I arrived here, I was the lone vascular surgeon at the university. I went to the chairman at that time, Dr. Jay Grosfeld, and said that if I was to stay I wanted to build the program. It’s not hard to build a program from one—you can only go up! I was given the opportunity to do it, and I will forever be indebted to Dr. Grosfeld for giving me that opportunity.

I think with my background at Northwestern, which was then the premier vascular surgery training program, gave me the confidence to think I could do the job since I had experiences in vascular surgery, which few others had experienced. Since then, the program has grown from just me to having eight partners. When I started, we had one secretary and two vascular lab techs, and we have far surpassed that number of associates and colleagues. We now have two training programs: We have a fellowship and a 0 + 5, in which you take a medical student and provide the training to become a vascular surgeon. Over the years bringing in partners, doing more research and getting into the educational world, we as a team have built the program. When vascular surgery became its own specialty, then the training programs started in earnest.

Even though I’m not an early adopter of things—I like to wait and see if things will work—with the 0 + 5 training program, I think we were the sixth program in the country to offer the training. The neurosurgeons were doing it, the urologists were doing it, ENT had their own medical student specialty training program, and I thought we certainly as vascular surgeons could do it as well.

It’s been a gradual building process, where you add personnel with expertise or new interest. Every time you hire a new partner, they take it to a new level and each one brings a new perspective that pushes the program forward. It’s not at all about what I do. The majority of innovation comes from those you have around you, what their thoughts are, and what their ambitions and interests are and the group interactions. When you start something like this, it may look like it’s something that I built, but it was a building by community.

Everyone brought their own talents and thoughts, and then we would advance. And that’s what you want to be doing, right? You always want to be moving forward, or you’re somehow going backward. If you asked me three years after being here whether we would be in the position we are in now, I could have never road mapped that for you. It’s a building process, and it’s been a good one, with good partners.

"The ability to travel abroad and provide talks to different groups in different places of the world is an eye-opening experience and provides some humility about what you are doing. You realize you don’t have a corner on the market of great ideas and great inventions."

VM: Being a division chief at a young age is an impressive accomplishment.

MD: Years ago, at one of our vascular meeting, I was amazed when someone said I was the youngest division chief of vascular surgery in the country. I had never thought about it and, in fact, I’m not sure if it was even true! (laughs) When they said it, I thought, ‘Well, I guess it’s possible.’ But Indiana at that time was in a growth spurt. I think I ended up in a good place at the right time, and I was able to build on that opportunity.

VM: You have delivered presentations all over the world. What are some of the differences you see and what can be adopted here to improve vein care?

MD: It’s been a transition. When I would travel 20 years ago, the US had all the newest devices and the money to finance it. And as things progressed, I saw that in some cases other countries had a better opportunity to get some of the newest devices because of how they handle the clinical experiments and regulatory issues. I have seen a change of who is doing the upfront work and research, and we see it in places that aren’t the US, which is a little sad because we always would like to think that we are on the cutting-edge. In some ways we are, but in other aspects, other people are. Just being here doesn’t give us a special edge on the newest idea or making things work. You sometimes see it happen in places you wouldn’t think of at all.

I’ve had some interesting experiences in Japan when I was a visiting professor. They are extremely respectful people but very formal from a cultural perspective, which is something that we are not used to here. It was interesting to see different cultures and experience them—Japan being just one example. The ability to travel abroad and provide talks to different groups in different places of the world is an eye-opening experience and provides some humility about what you are doing. You realize you don’t have a corner on the market of great ideas and great inventions. It’s always amazing to see what people are doing elsewhere.

"I’m always a little concerned when the media looks to the American Heart Association to speak on venous disease when they have at their disposal all the American Phlebologic societies who have a major interest in this disease process."

VM: Is there anything you saw during your travels that you feel should be adopted here?

MD: Early on, aortic aneurysm endografts were being developed in South America. While that was an aspect of early development located in South America, I found that sometimes the skilled surgeons in some South American locations simply couldn’t afford the newest, less invasive tools that we had here to treat saphenous vein reflux, and that vein stripping was still being used. You can do a very good job and become very skilled at open vein removal, which I saw was occurring there.

I realize that a lot of things are driven by economics and by the ability to get the most up-to-date tools. In some cases, the need will foster innovation, and I have been so impressed by people who have come up with newer ideas to deliver better treatment for their patients where you might not think they have the resources to do it. An example of this is pin stripping, which was developed years ago but was being improved on. I’m sure most people wouldn’t even remember doing this operation anymore because everybody uses a minimally invasive procedure. I know that some of my residents have never done a vein stripping, but they have certainly had an experience in radiofrequency ablation, lasers, and sclerotherapy.

VM: Circling back to your special interest in end-stage venous disease, can you tell us more about this?

MD: I became interested in venous valve work because I was treating patients who had recalcitrant venous ulcers. They would have a venous ulcer, which if you were extremely diligent, you would get to heal for four to six months, and then it would come back and you would have to treat it all over again. That’s how I became interested in end-stage venous disease; patients’ I was treating had a need which I could not fulfill. If other physicians had exhausted what they had to offer the patient, then the patient would come to the university, and I became the avenue of last resort. This was often the case for patients with end-stage venous disease.

VM: You mentioned earlier how your personality drove you to a specialty that provided a more immediate outcome, yet here you are working toward solving what is essentially a chronic problem!

MD: You are exactly right! (laughs) But you know what? Vascular disease, whether arterial or venous, is a chronic problem. One of the real plusses of being given the privilege to treat patients with vascular disease is that you follow them forever. I’ve been following some people for 33 years, trying to help any way I can. I sometimes get calls asking me for advice on other procedures that aren’t related to vascular disease. You form a relationship with people, and certainly with people with end-stage venous disease. That kind of relationship is what binds you to the person, and it is an important part of what we do.

VM: What are your thoughts on the integration of the various societies into one society and working more closely together?

MD: I don’t know exactly how that would work. I’m on the other side of it now being a past president, and now other people are the leaders and making those critical decisions. I think what the world needs is an advocate for venous disease. Vein disease is not as ‘glitzy’ as arterial disease or breast cancer or certain other diseases. It’s a quality of life and sometimes infectious issue. Yet, it affects millions of people throughout their life and in a negative way.

For example, if you go to the hospital for an operation and are given the proper treatment so you don’t get a clot in your deep veins, proper prophylaxis for deep vein thrombosis, then your quality of life from that time forward is much improved. You won’t get the post-thrombotic syndrome; you’ll never see edema or venous ulcers or the other things that come from it. So we have to educate people and doctors, and if all the venous organizations speak with one voice, they should be able to educate and advocate for venous disease.

I’m always a little concerned when the media looks to the American Heart Association to speak on venous disease when they have at their disposal all the American Phlebology societies who have a major interest in this disease process. I think these organizations should be the voice for venous disease in the world and especially in our country, because a lot of things that happen on a legislative or federal stage is based on what the experts say because that is all the legislators have to go on.

I don’t know how all the venous organizations would be merged into one, or even if they should be, but I think if you are a venous organization you ought to be working together to be the voice for your patients and the people you are taking care of. The politics of medicine is as important sometimes as the basic care we provide.

The biggest thing that I came away with from my experiences with venous organizations, predominantly the American Venous Forum, is the closeness I feel with the people who do venous work, because it is such a chronic problem and not all the answers are known. I feel closer to them than the people I have met in a lot of other organizations. I think they are an open-minded group of people, easy to talk to and accepting of new approaches to patient care, maybe because that is what they have to do in their daily care of patients. They are good people to be involved with, open to change and innovation as part of their personality, not as a part of the job. It was and is something I want to be a part of.

VM: Any closing thoughts?

MD: If my wife, Rosa, wasn’t there taking care of everything at home, I could not have realized any of the accomplishments and opportunities I have been privilege to do in my professional life. You have to be able to go to a safe place, and for me home was that place, and I can’t thank her enough for that place.

My mentors, the guys that I trained with like John White, and my partners over the years like Al Sawchuk, Dolores Cikrit, Steve Lalka, Mike Murphy and my other partners past and present as well as each and every one of my residents will have a special place in my heart forever. The same is true for my administrative staff, nurses, vascular lab and radiology support staff—they are the greatest.


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