Post written by GIE Senior Associate Editor David L. Diehl, MD.

Dr Michael V. Sivak Jr is one of the giants of endoscopy, not just in the United States, but across the world. He was “in the room where it happened” for many important developments in gastroenterology and endoscopy that have since become routine practice. 

Dr Sivak was President of the American Society for Gastrointestinal Endoscopy (ASGE) from 1989 to 1990 and awarded the ASGE’s Rudolf Schindler Award in 1997. He was Chair of the Department of Gastroenterology at the Cleveland Clinic in Cleveland, Ohio, from 1988 to 1993, followed by Chief of the Division of Gastroenterology at Case Western School of Medicine in Cleveland from 1993 to 2005.

He became Editor-in-Chief of Gastrointestinal Endoscopy at a very critical time in the development of endoscopic technology and served in this role for 8 years from 1996 to 2004. Dr Sivak has been retired from practice since 2006. This year, he received the President’s Award at the ASGE’s Crystal Awards.

I was recently diving back into the history of EUS in the United States and came across an interview that Dr Sivak did with our colleagues Drs Ashley Faulx and Gerard Isenberg. There was an entertaining video interview, but no transcription was available. Using voice recognition then Claude artificial intelligence to help with formatting, I generated a transcript of the interview. We are publishing it here on Endoscopedia so that more will be able to access it. (Watching an almost 1-hour interview can be challenging these days!) I hope that you enjoy the interview as much as I did!

To continue reading about Dr Sivak, check out the article in the June issue of iGIE, “Character is destiny: the Endoscopic Ultrasound Users Group and the beginnings of endoscopic ultrasonography.”

Interview with Dr Sivak by Drs Faulx and Isenberg

Dr Faulx: Both of us are active endoscopists and members of the ASGE. We’ve developed careers in GI endoscopy thanks to our mentor—and the mentor of many endoscopists around the globe—a true pioneer and giant in our chosen discipline, Schindler awardee Dr Michael V. Sivak Jr. Mike, it’s a pleasure to welcome you back from a very successful retirement to University Hospitals in Cleveland.

Early years and path to medicine

Dr Faulx: Let me start off with your early years growing up in Erie, Pennsylvania. I know your father was a physician, and I know your siblings also went into medicine. How did your childhood influence you, and did it play a role in your choice of career?

Dr Sivak: First let me say it’s very nice to see the 2 of you, and I’m happy to see that you’ve turned out so well because I remember at the time there was some question about that—but we’ve both done extremely well, and I’m very, very proud of you.

Erie, Pennsylvania—that’s a long time ago. I guess when I was growing up there was never any question that I wouldn’t go into medicine. My dad was a doctor—he was an ophthalmologist, actually, ophthalmology/ENT, because in the early ‘40s when he started, they were all sort of sandwiched together. He was the first, and then came his brothers, and then I have 2 brothers who are physicians— actually 1 1/2 because 1 is a psychiatrist—and I have 4 cousins who are doctors and a whole bunch of nurses scattered in there. It’s all very disgusting. But to answer your question, I just never thought about anything else.

Choosing gastroenterology

Dr Isenberg: Tell us about your start in medicine. Was gastroenterology a subspecialty at the time, and how did you end up latching on to endoscopy?

Dr Sivak: I saw that question—was gastroenterology a subspecialty? I’m old, but I’m not that old. Yes, it was a subspecialty. It existed.

I went to the library at what was then Philadelphia General Hospital and looked up all the various textbooks on all the subspecialties. I think I could have been a good surgeon—I was really good at that in medical school—but it was kind of foreordained that I was going into medicine. Anyway, I got all the various subspecialty textbooks, and I found Henry Bockus’ textbook, which at the time I think was 3 volumes. The thing that impressed me about GI is it had way more organs than anybody else. I had no idea about endoscopy at the time, but I thought this is much more interesting than just cardiology—that’s 1 organ, things are pretty much cut and dried. Nephrology…GI’s pretty big. So, I was impressed by the size of Bockus’ textbook. That’s literally how I chose.

Music, astronomy, and their influence

Dr Faulx: I know that you’re an amazing musician and aspiring composer, as well as an amateur astronomer. How did those hobbies influence what you do?

Dr Sivak: Music I hated until I got into high school and met my first clarinet teacher, which threw a scare into my father, who thought I was going to be a musician. But I’ve done that all my life with various interruptions—medical school shut down the music for a while.

Dr Isenberg: What was the name of your band?

Dr Sivak: It was the Mike Sivak Orchestra when I was in high school. When I was at the Cleveland Clinic as a fellow, we had a doctors’ band, and the name of that one was the Arrhythmias. We were pretty good. I would bring in some of my other musician friends to populate the various chairs, and we would play dances and things for the clinic.

As for astronomy, I don’t do much anymore because West Virginia, where I live now, is not very conducive to astronomy. But as you know I own a lot of books—you can never have too many books—I do a lot of reading, the stock market keeps me busy, and so forth.

As for how it influenced my career and endoscopy—I’ve always had this theory that good musicians make good endoscopists. It’s a little bit the same kind of eye-hand coordination, but there’s also an interpretive part to it as well. I don’t know if you remember, but I would always start out by asking, “Are you a musician?” when I would begin work with one of the advanced fellows. And of course, astronomy—you’re looking through, I guess we don’t look through little telescopes anymore, those are gone. I suppose there is some influence, but by and large, it’s probably unconnected.

Mentors and the advanced endoscopy fellowship

Dr Faulx: You were a mentor to so many of us, and you started one of the first advanced endoscopy fellowship programs in this country. Who were your mentors, and how did they influence your career?

Dr Sivak: It’s an interesting thing about what I call legacy. My most immediate mentor was Ben Sullivan, who was at the Cleveland Clinic when I was there as a fellow. Endoscopy—by modern standards—was pretty primitive. We had just come out of the rigid endoscope era, candlepower, well, they didn’t have electricity in the early days. I believe the gastric camera, for example, had the light bulb inside the patient, which would be just unacceptable nowadays.

Ben Sullivan had spent 20 years in the Army and rose to the rank of Colonel. He had been at Walter Reed and was John Foster Dulles’ physician. He was interested in endoscopy, and somehow we clicked. Now the interesting thing is that the person who taught him endoscopy was a fellow by the name of Eddy Palmer, who was also an Army Colonel. I never met Eddie, and I suppose he’s probably deceased now. So, your legacy of training through me goes back through Ben Sullivan, through Eddie Palmer, and to someone unidentified in the distant past. Ben knew Schindler—he was not part of the original 6 or 7 people that formed the American Endoscopy Club (which ultimately became the ASGE I think in 1941), but he knew all of those people. That’s pretty much how it started.

Dr Isenberg: And the advanced fellowship program?

Dr Sivak: Peter Cotton. Once upon a time Peter invited me to London. He used to have these courses—brief little sessions, not all that little—with a small number of people, probably not more than 10 or 12. He would do endoscopic procedures in the next room that were shown on television—at that time, you put the television camera on the endoscope. I always wondered how Peter was running all over the world giving talks and playing golf and still keeping the store running. He had at that time 3 young men working for him who were not trainees—these were fully functional gastroenterologists who had come for some sort of additional training. I thought to myself, what a great idea.

What I did that was different is I formalized it. At the time, I was at the Cleveland Clinic, and there was much more latitude about the things you could do. The problem, of course, was money—how would you pay a salary? I figured that out, formalized it, decided on certain things we wanted to accomplish, advertised it, and there was no lack of applicants. That’s pretty much how it started. (Laughter and aside about whether fellows received salaries.)

Women in advanced endoscopy

Dr Faulx: Back to your advanced endoscopy fellowship—I know you try to act a little chauvinistic, but we know that’s not really true. You have 3 daughters who are all very career-oriented. Tell us about women in advanced endoscopy.

Dr Sivak: It got to the point that I was getting as many as 40 or 50 applicants for the program. You couldn’t interview 40 or 50 people, but I would interview as many as 10 from the pool. Along came this young woman from Johns Hopkins, Mimi Canto. The interviewees are always ready for all the standard questions, so I would have a list of every question I could think of that wasn’t standard like, “What do you do in your spare time?” But anyway, I sat back and said, “So, young lady, why do you want to do this?” And her chin went up and her eyes got really big, and she said, “Oh, I want to be just like you.” And I said, “Okay, kid, you’re in.”

Dr Isenberg: You used to ask them also if they had the fire and the guts, right? The FIG principle?

Dr Sivak: The fire and the guts, yes. Where do you get this stuff? It’s passed on from fellow to fellow.

I honestly tried to pick the person I thought had the most fire and the guts and who would also follow the idea of endoscopic research—we were trying to build the idea of endoscopic research, and that was an important criterion. I tried to sense whether they would pursue academics or make some sort of contribution. Looking back, I was successful mostly but not always. They have all become accomplished physicians and endoscopists, but some stuck to academics more than others.

Endoscopic research and key contributions

Dr Faulx: How did you get interested in endoscopic research, and how did you learn how to do research?

Dr Sivak: One of the reasons the ASGE was formed is that endoscopy, way back in the ‘40s, ‘50s, even ‘60s, was sort of the poor stepchild of gastroenterology. It just didn’t get the respect it deserved. The people who did it were derided to some degree by the more “intellectual” gastroenterologists. That’s kind of the origin of the split—the logic of why the ASGE exists goes back to politics and people’s attitudes.

Starting in the early ‘70s, I sensed that was the case and had the idea that we should make this mainstream medicine—we should study how we do things, why we do things, whether they really work. Institutional Review Boards were not nearly so strong, and you did some things because they seemed logical, not because you knew they were right. I thought that wasn’t the right way to go. We should try to figure out how things work—are the things we’re doing really worthwhile?

One example is colonoscopic polypectomy. The technique was developed by Hiromi Shinya and Hiroshi Ichikawa, who diagrammed the idea on the back of an envelope, the kind your sterile rubber gloves came out of. Hiroshi still has the little diagram, I believe. Everybody told them not to do it. Hiroshi was working for Olympus, who said it was too dangerous. But they went ahead and did it—and this was before there was any reasonable proof that polyps were the forerunners of cancer. It wasn’t all in a logical order—it was more, “Fire, ready, aim.” After that, John Bond and all those fellows—the National Polyp Study — finally nailed it that polyps were indeed the forerunners of colon cancer.

Sclerotherapy was another one, first done around 1939. The question was whether shunt surgery could save people from dying of variceal bleeding. These poor patients would be in the intensive care unit for weeks—they’d stop bleeding, then bleed again, eventually their liver would deteriorate. It was a downhill, disastrous, costly, agonizing spiral. Two or 3 of us resurrected sclerotherapy and figured out how to do it through an endoscope. It was miraculous—you could spot the bleeding point, stick the needle in there, and it stopped. Of course, there was no randomized controlled trial. Had there been, we might have realized sooner that it works okay but has some downsides. Then along came banding, which was a refinement of the same idea.

That’s how things were in the ‘70s. I just thought we should apply scientific methods to how endoscopy is done and why we do it.

Greatest contributions to endoscopy

Dr Isenberg: I know you think colonoscopic polypectomy is probably the best contribution to endoscopy for patients. Would you agree?

Dr Sivak: Yes, in terms of what did we do for good for humanity in GI, I would say that’s right up there. A close second was treating cholangitis via ERCP and saving patients—that is equally dramatic. The only reason polypectomy outranks it is that there’s way, way more colon cancer than cholangitis.

Dr Faulx: You’ve made significant contributions with sclerotherapy. You and Charlie Lightdale were among those who brought EUS from Japan to this country. You’ve had a career invested in endoscopic technologies including optical coherence tomography. What are your proudest contributions?

Dr Sivak: EUS was very interesting. Olympus came to me and Charlie—we were the first 2 people, I think, in the Western Hemisphere to do EUS. There weren’t all that many people in the Eastern Hemisphere either, for that matter. Olympus had no idea what to do with it, and we had no idea either. Charlie, being smarter than me, decided he would study the esophagus—brilliant, great approach, you can get in there and see everything. Like an idiot, I’m thinking, “Wow, we could see the pancreas with this thing,” which is of course much, much harder.

At the clinic, not knowing all that much about US, I got a stack of books and started reading. I also got a guy from the radiology department named Craig George and persuaded him to work with me. We scrounged up an Institutional Review Board to cover us. The problem with Craig George was that he was a big guy, and the display unit was a refrigerator-sized thing that took 2 men and a boy to push into the room, with the tiniest little screen. Craig being a big guy with a big head, his head was in front of the screen, and I couldn’t see anything, so we developed a system of hand signals. Every now and then he’d stick his head out of the way, and we’d see something. We had to do a screen capture with an old Polaroid. But we succeeded in ultimately finding the pancreas. We didn’t hurt anybody—I’m not sure we helped anybody—but that’s the way that started.

Of all the things, if I had to rank them, I think the most dramatic to me—and one of my entries into the upper echelon of endoscopy—was sclerotherapy. I remember presenting in Chicago. We had made a videotape of this—we didn’t need science because we had a videotape of blood pouring out of a varix. We made the videotape by clamping a 16-mm Arriflex camera onto the endoscope. It was extremely heavy, so Ben Sullivan was standing there holding the camera while I went after this varix that was pouring out blood—probably not in the best interest of the patient, but sure enough, I got the needle in, and the varix started spurting and all of a sudden stopped. I showed that in Chicago, and that was enough.

Banding was obviously better, but you have to realize what was happening with these patients at the time. Even though we didn’t save any lives ultimately, we certainly saved the blood bank and some other resources, and we maybe made their demise a little easier. The distal splenorenal shunt trial, I forget the investigators, showed they didn’t save anybody either; they just changed the mode of death but at much more cost and difficulty. Then along came banding—John Goff and that big, tall surgeon from Denver (Greg Stiegmann)—and that just nailed it.

Textbook and editing

Dr Isenberg: Now most trainees use the internet to look up information. But you were a religious, authoritative source, both on television and in print. What motivated you to write your textbook? At the time, it was not the first GI textbook, but it was the first comprehensive textbook that tried to put everything in 1 place.

Dr Sivak: Part of it was just an effort to see if it could be done. I got a good response from a lot of people. There was also an editor at the clinic who helped perfect my editing skills. She brought to me the editor from Saunders who was looking for people to write books. She said, “If you do it, I will help you,” meaning help with the editing from the standpoint of English, punctuation, and grammar.

It was partly a spur-of-the-moment decision and partly to see if we could set everything down. And going back to this, we were second-class citizens in gastroenterology. I thought, “We can strike a blow for the underclass here.” All of that went into it. Of course, it was a lot harder than I thought. That’s how I got into editing.

Dr Faulx: You’ve worn many hats throughout your career, including Chief of the Division and Editor of Gastrointestinal Endoscopy for many years. You had just finished your textbook, you were trying to grow the division at University Hospitals, and then you decided to take on the editorship. What led you to do that?

Dr Sivak: Stupidity, I guess. I don’t know. The person who succeeded me as Editor was again Charlie Lightdale—our careers have intersected in so many ways. He had been the Editor before me, and Reina, his wife, was the Managing Editor, so there was a formula there.

I had pretty much finished everything I could do in the ASGE except that and, again, it was in part wondering if I could do it. I always wanted to be the captain of an Iowa-class battleship, but there are no more Iowa-class battleships, and being the Editor is kind of like being the captain. I was drunk with power or something. My wife Donna became the Assistant Editor, and we did a lot of expansion. I’m not sure we did everything as fast as the ASGE wanted, but the one thing I’m proud of is that we tried to stick to our editorial principles as best we could. And it’s not easy—I’m sure there are a lot of people out there who hate me for rejecting their manuscripts.

Involvement with the ASGE

Dr Isenberg: How did you become involved with the ASGE, and what was the most important role you played?

Dr Sivak: My mentor Ben Sullivan had been President of the American College of Gastroenterology and received the Schindler Award. He always talked about it. But when I started as a staff member at the Cleveland Clinic, I didn’t have anything to do with the ASGE.

Steve Silvis, by the way, had a textbook before I had a textbook; it wasn’t as comprehensive as mine, but it was a good book, and I used ideas from it, to give credit, he was President of the ASGE. So, I wrote him a letter, which I still have, and said, “Dear Dr Silvis, I do teaching every day, and I know a lot about teaching. I think I should be on the Education Committee. Would you give me a job?” And he did.

That’s when I met Loren Pitcher, who was also a President of the ASGE. Loren Pitcher was Chair of the Education Committee, and he sort of brought me along. The next thing I knew, I was Chair of the Education Committee, then Secretary-elect, and so on from there.

Dr Faulx: What changes did you observe in the ASGE over the years?

Dr Sivak: The obvious thing is growth. One of the most important things we did, we decided we needed to save money and invest it. Jim Borland had some financial sense. In addition to the growth, we started saving money and investing it. I remember the stock market crash of ‘87. We had a conference call and suddenly realized what fiduciary responsibility means—that means if you lose all the money and you’re not insured or protected, as officers, the membership can sue you. We were on a conference call watching things drop like a stone. We decided not to sell, and that turned out to be the right call. We had selected a money manager named Robert Appel from Neuberger Berman in New York, and it all turned out to be very successful.

Far and away the biggest change was growth. In my early days, it was a bit of a good-old boys club—women were somewhat excluded, which I’m not proud of. At the time I started, only 6% of gastroenterologists were women. It’s currently up to 23% and growing, which is all good.

The other thing is that a lot of the really big developments happened from about 1975 through 1985 to 1990. I wrote an editorial before I retired about how I thought things had risen so rapidly—it was like every year, “What’s the next great thing?” There was PEG, EUS, ERCP, and then all the therapeutic ERCP—the door was just opening. I thought that period would probably be looked back at historically as the golden age, when things really developed. The ASGE promoted that, and people realized this field was getting bigger and bigger.

Famous quotes and teaching philosophy

Dr Faulx: We’ve amassed a number of quotes, wisdom you’ve passed on in short blurbs that have been transmitted through the generations. Do you remember some of your favorites?

Dr Sivak: I don’t know what’s best—you’re the judge of that.

Dr Isenberg: One of them being that intimidation and sarcasm—

Dr Sivak: You have to understand the teaching value of sarcasm, ridicule, and intimidation. It works. It’s very good. “Where did you learn anatomy? Where did you take anatomy? Where did you go to medical school?” That kind of thing.

Dr Faulx: You’re also fond of quoting famous people, like Clint Eastwood.

Dr Sivak: Oh yeah, my favorite sociologist. “Feeling lucky today? If you’re going to do that, you’ve got to ask yourself one thing, ‘Do I feel lucky?’” And then the other one I like is Voltaire’s: “Perfect is the enemy of good.” Why do I say that? Because it’s true.

I guess I was a pretty good teacher of endoscopy. There’s an old skit by Bob Newhart called “The driving instructor”—that’s what it’s like teaching endoscopy. You’ve got this enthusiastic young person behind the wheel of a 2000-pound car with 400 horsepower, and you’re sitting there trying to control things with your tongue pretty much. He has a line in there about speaking to his predecessor who had somehow been injured: “How fast were you going when you jumped out of the car?” “Going 60 miles an hour.” And “where were you?” “In the driveway.” Something like that.

The second thing about teaching endoscopy is that 90% of everything is half mental. You’ve got to get inside the head of the student. They fall into 2 extremes: aggressive and overconfident or shy, timid, and overly cautious. Some of the verbal stuff is designed to get them out of whatever extreme that is. And who said, “Ninety percent of everything is half mental”?

Dr Faulx: Yogi Bear?

Dr Sivak: Yogi Berra. Baseball is a source of wisdom—you’ve got to realize that.

Endoscopic training

Dr Isenberg: Do you have any thoughts on endoscopic training and how it’s changed over time?

Dr Sivak: It still basically comes down to the driving lesson. The secret to teaching somebody to be a really good endoscopist is colonoscopy. Every colon has its own personality—live by the loop, die by the loop. But to really understand the endoscope, there’s another favorite the fellows reminded me of the other day: Zen in the Art of Archery. It’s a book by a German author from the ‘30s about a famous Japanese archer who could hit the target blindfolded. It’s a kind of man/machine interaction, and that’s kind of what it is with an endoscope. Some people can make that thing do things better than others. Everybody can learn the basics, but to be a virtuoso with an endoscope takes a little bit of special talent.

Dr Faulx: Another saying you used to tell us was that if we were to know the secret of endoscopy we would have to get to the mountain top, someplace in Japan.

Dr Sivak: Of course, of course.

Advice to trainees

Dr Isenberg: What advice would you give to people who want to develop a career in GI endoscopy?

Dr Sivak: The first question is: do you really want to go into medicine? I’m ambivalent about that. I never advised my oldest daughter one way or the other. She’s an orbital surgeon, and I think knowing what I know now about the way medicine is going, I might not have gone in. But that’s the first question.

Once you get past that, you really have to have the fire and the guts—damn the torpedoes, I’m going to do this. Then part of the question is: what are your natural abilities? Am I good with my hands? Could I be some sort of surgical kind of person? Do I really like talking to people, listening to people’s problems? By the way, my answer was no—I’ve learned to do it, but I don’t really like it. So, you think about your natural aptitudes, you make lists of yeses and noes, and then you throw all of that out and do what you feel like you want to do. You might make a mistake, but that’s okay.

The other question is: where is the field going? When I was with Ben Sullivan, we had those crude 1-way deflection scopes. You had to pump the air in with a sphygmomanometer bulb and had a syringe to wash. It was not much. But I somehow just knew: this is going someplace. So, that’s another question: do you really think endoscopy is going someplace? Is this a growing field, or should I go into gene splicing or something like that? Only an individual can answer these things.

But after you get done making all the lists, it comes down to: you like it or you don’t like it.

Dr Faulx: I work with the medical school every year on panels to help students choose a career direction. My sense is that it’s the people you meet—you and Dr Chak who led me here—role models who form our ideas about how we want to be.

Dr Sivak: You’re very astute as usual. Role models. It probably plays a bigger influence than anybody knows, all through your education. Role models—”I want to be just like you”—no doubt about it.

Proudest achievements

Dr Isenberg: You’ve had an amazing career, one that many people would say is one of the most ambitious anyone could have. You’ve worn all these hats that few people have worn even one of. What’s your proudest achievement?

Dr Sivak: Oh my God. Besides my professional career, that’s the kids.

Dr Faulx: And professionally?

Dr Sivak: I played second clarinet in the Morgantown Municipal Band. I’m pretty proud of that. (Laughter)

People have been after me to say who is the best fellow I ever had, and there really isn’t one. If I could make a composite, I would take something from this person and that person. There were some that were smarter, some that were more adept, some that were not so adept. All of them had strengths and weaknesses just like everybody else, so I’ll accept the characterization that my trainees are what I’m most proud of in my career.

If you asked me now that I’m retired what I miss the most, it’s the interaction with my colleagues and with what I call the trainees or students. That’s you guys. I don’t know if I could do it anymore—millennials scare me—but I don’t know if the old methods would still work.

Dr Faulx: Thank you so much for speaking with us.

Dr Sivak: You’re very welcome. I’m glad you both turned out so well. I’m not surprised, but thank you.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.