From my neurology residency, I progressed to my neurocritical care (NCC) fellowship, not so much because I had the wherewithal to know that a cerebrovascular year of post residency training is the stepping stone to NI for neurologists, but because I was also interested in intensive care medicine.  Frankly, this had been my game plan for longer than NI.  Nowadays, I meet neurology residents and fellows in various levels of their training who already have defined plans for a field of neurointervention; I applaud their forethought and clear headedness.

E Lin: Did the choice of a NCC fellowship have any influence on your decision to continue your pursuit of NI?

S Janjua: During my NCC fellowship at Columbia University, I was blessed to be part of a good research environment and first learned the value of peer review and national representation.  It was a top-notch program with some of the finest thought leaders in the field.  There were some more difficult aspects of the field to learn too.  Ensconced in the program year round, rather than just a one month elective exposed more interdepartmental rivalry and politics, which unfortunately I saw was far more common place than the Hollywood style rosiness I’d witnessed in Los Angeles.

Still, directly taking care of the patients in the Neuro ICU brought me even closer in the face of the key role endovascular therapy has for many of these patients.  This “interventional stuff” was no longer a side thought wandering for me at this point.  This was a clear subspecialty, and by all rights, a subspecialty every bit as important and routine in the broader discipline of Neurology as movement disorders or EMG.  My interest in Interventional Neurology was a mere spark no more, but a firm career goal.

E Lin: How did you embark on your NI career path and were there mentors who guided you on your pathway to success to finding an NI fellowship?

S Janjua: This was before the era of the HERMES trials, before flow diverters–Neuroform was still a novelty when I was in my neurocritical care training (but the internet was invented), so fellowship opportunities, let alone job opportunities, were not as widely available.  Obtaining the training was the first key to my success, and for that I am ever grateful to Dr Adnan Qureshi, first president of SVIN, and to Dr. Stephan Mayer, my then NCC fellowship director, who pointed me in his direction.

I didn’t know of too many other contemporaries of mine at that point who were also looking for interventional fellowships (or jobs) with whom I could share notecards and tips.  I’d meet other fellows around the country as I was interviewing, most were neurosurgeons, occasional few were radiologists. The neurologists were out there interviewing too, no doubt, but our paths hadn’t crossed.  After all, SVIN hadn’t yet formed as a society back then.

One memorable conversation I had with one of the interventional neuroradiology fellows makes me laugh now.  “What hospital is going to put in a biplane room for a neurologist?” He said to me when I sought advice while securing a fellowship spot.  Nowadays, it is not even a question, hospitals will bend over backwards to secure a neurointerventionalist—and one who can administer both the IV tPA and take the clot out is a gold find.

Neuroendovascular fellowships are generally beloved times for us.  Despite the heavy and hectic call load, the breadth of cases we see without the stress of being the primary operator is really a unique experience to cherish.  Back in the pre pandemic era, national fellowship meetings hosted by various device companies would bring together numerous trainees with diverse backgrounds from across the US, all at the same level of training, to be wined and dined and also to learn a little about their devices.

At some of these meetings, I remember several radiologists questioning the quality of my training and degree of hands-on experience.  When we shared experiences and I’d told them how I’d already injected glue and placed coils, they were quiet.  Again, I am eternally indebted to Dr. Adnan Qureshi for teaching me.

E Lin: Given your early experiences in the field, were there any challenges you faced entering a male dominated specialty and could you share some of your insights?

S Janjua: When we’d sit down to our lavish dinners, one notable feature of these meetings was dominance of men at the various table at dinner time.  It was not often I’d meet another female fellow, let alone another woman interventional neurologist.

Although I am heartened to see more and more women entering this field every year, it is still an overwhelming sea of dark suits and male faces at “embo clubs” and peer group meetings.  Certainly, at the national meetings the gender disparity lessens, but it is still not uncommon that other attendees at these events might take me for a device company associate rather than a physician in the field.

E Lin: Have you seen any change in representation as you progressed from training into your successful career and can you share any insight into the barriers that contribute to the disparity? What has it been like for you in the field?

S Janjua: While I cannot satisfactorily answer why women don’t go into this field as much as our male counterparts, the underrepresentation of women in neurointervention is not much different than in surgery.  Is it perhaps a difference in our innate interests?  I am not a child psychologist or a gender psychologist, but does it go as deep and far back as the predilection for boys to play with trucks, toy cars, Transformers as opposed to dolls?

Some may find such a generalization offensive.  However, generalizations are the necessary evils we must face to first try to broach any subject.  I hold no judgement against boys who play with dolls (they actually do, but just call them action figures), or girls playing with trains; this is a mere statement of observation, of modes and means, which as vascular neurologists interested in research, we are all familiar with.  In any case, I had my own beloved Barbie dolls as a kid, and now I am an interventionalist, so I’m not sure if this generalization holds true for me.  I’ll probably ask my nephew to try to devise a science experiment on this.

This theory also supposed that it is women themselves choosing not to enter interventional fields as opposed to an active and subversive effort keep us out of them.  This is a dark truth that pervades medicine, if not all walks of life.

Most women at some point in their lives have experienced gender discrimination.  And most perpetrators don’t realize they are doing it.  It’s not necessarily sexual harassment or disparaging comments, but may be unwitting or calculated moves that undermine women’s efforts.  Dr. Jensen pointed out a few such instances in her interview.  I’ve heard stories from various women neurointerventional fellows, about how the bawdy jokes during down time in the angio suite tend to leave them out of the circle.

I don’t think I’d ever really experienced or at least been aware of any gender discrimination in my career until my interventional fellowship and then as an attending.  Perhaps I was just never aware before.  It might be the decision of an anesthesiologist to deny coverage for my acute hemorrhage embolization in favor of a less urgent elective case with a male surgeon, or people’s choice of language.  On one occasion, where I had to argue to allow a new attending to perform a thrombectomy on his first call, I was actually told to not get ‘hysterical.’  I have a hard time believing a male physician in the same circumstance would have been called hysterical when simply advocating for a patient.

If this happens at the attending level, what are the subtle things happening when we’re in training?  Did the male surgeon give a bit more elbow room in the OR to the male student or make comments when the female students or residents—similar to what I experienced in that conversation during my own fellowship, where the bias was against neurologists performing endovascular procedures—that quietly discouraged them from entering interventional fields?  It’s a lesson for us to remember that our words matter and can make deep impressions on young medical students or others working alongside us.

E Lin: Given your extensive experiences, can you share how your practice has changed over the years from your initial years just out of fellowship?

S Janjua: I had chosen a community hospital in Brooklyn as my first job.  How had I gravitated so far from declaring an interest in bench research during my residency to working in private practice?  Having witnessed the corrosive nature of interdepartmental politics, I valued very highly the prospect of going someplace where there would be none of that.  But ‘none of that’ meant no concept of an interventional service at all.  The hospital would install a biplane (touche to the non believer of my earlier fellowship) but I’d have to build the program after that.

Nowadays, it is a neurointerventionalist’s market in job hunting. Especially since 2014 with the positive findings of the major ischemic stroke thrombectomy trials, NI is no longer the pure domain of the academic medical center.  Many smaller hospitals want to secure thrombectomy capable designation to maintain the EMS routing to their hospitals, which of course requires a neurointerventional program.  However, as frequently as ischemic strokes occur as a proportion of a community hospital’s annual volume, the uniqueness and complexity of neurointerventional procedures may end up far out of balance compared to the capabilities of surrounding specialties. This can be a very isolating experience for a solo practitioner neurointerventionalist in private practice, when dealing with critical patients requiring risky therapeutic maneuvers, and trying to find a sympathetic senior female proceduralist will be even harder.

Despite these types of hurdles, I have found immense satisfaction in taking a program from its inception in two different places on both coasts of the United States (Brooklyn, NY, and now in eastern LA county).  The regulations of medical practice and constraints on physicians are vastly different, but the outcome of a successful program remains the same.

And even if a woman—any interventionalist– manages to overcome gender discrimination or even simply professional rivalry on specialty lines, just as Dr. Jensen said, one still has to be good at it, which may also mean believing in yourself and your skill in the face of adversary.  Sometimes competence in itself threatens others.  One has to acquire early on the emotional intelligence and psychological skill to package recommendations in a manner easy to digest for others.

E Lin: How do you envision improving the interests and involvement of women who would want to embark on a fulfilling career in the NI and medicine in general? Have you had an opportunity to impart your wisdom to others?

S Janjua: We can build coalitions, women in SVIN, women in medicine, women in any entrepreneurial professional field are a good network from which to draw strength, and we should give back. When we have those medical students, who want to tag along and watch cases, or shadow us in clinic, remember that we were once those medical students, and a single unthinking word could dissuade or persuade these young doctors.

To that end, my single proudest accomplishment in this field is having trained one of my residents in the field of NeuroIntervention.  When I read the accompanying interview of Dr. Jensen, who pioneered vertebral body augmentation therapy, and read the feats and accomplishments of many sorts of various women and men colleagues in the field, I cannot say that I have contributed on their same level.  And even in the realm of post graduate education, certainly my own mentor, Adnan Qureshi, and others like Sam Zaidat, just to name a few, have trained far more people.

But at least if nothing else, in private practice, launching two de novo Neurointerventional programs in two different community hospitals, at critical time points where my mentee, Dr. Kessarin Panichpisal was first a neurology resident, and then a neurointerventional fellow, gave her an opportunity to learn about this wonderful discipline.  And now I am happy to see how she has thrived in her own practice in Wisconsin and no doubt is helping more patients, and paying it forward with more medical students.

E Lin: What do you see as the future of our field and for your illustrious career in NI?

S Janjua: This 21^st millenium is an era of information abundance and technological feats.  Going to the moon is not just the purview of the federal space program anymore.  Private entrepreneurs commission their own rockets.  Big data leads to big discoveries.  In the same way that giant aneurysms can be flow diverted in the community setting and top-notch fellows can be trained outside the typical academic environment, I believe research, even basic science, can be done in the private setting.  Globalization and person to person point of exchange is opening new and vaster networking opportunities.

Thus for the next phase of my career, I would like to see more growth of private and research partnerships that can truly inform and benefit a larger population of stroke patients.

Elin: Any Parting words?

S Janjua: When Dr. Panichpisal’s fellowship came to an end (seemingly too fast), she gave me a good bye card which served as an apt anthem for the two years she’d spent with me, inaugurating our program in a community stroke center in the eastern edge of LA county.  Tough times don’t last; tough people do.

I’ve adopted that as one of my mantras.  Medicine is a tough specialty, new viruses, new tools, new drugs are constantly thrown at us.  Science perseveres.  Woman continue to break ground in all walks of life, and the field of neurointervention is just one of them.