President’s address to the American Society of Transplant Surgeons (ASTS) Excerpt Winter Symposium, January 14, 2016 Charles M. Miller, President
(Full speech is available for viewing at http://asts.org/education/events-meetings/winter-symposium/previous-winter-symposia)
Beauty and the Beast
Part 1 of 2
First, I want to say that the last 8 months as President of ASTS have been an absolutely incredible experience. It’s been a terrific opportunity and honor. To say I’ve learned a lot from colleagues and ASTS staff would be an understatement. While very busy and sometimes challenging, mostly it has been a joy having the bully pulpit and representing this great Society in discussions and conversations with colleagues, thought leaders, policy makers, regulators, and allied organizations.
For organizations like ours, the million-dollar question is always – as a field and as a community, where are we and where do we want to go? The theme of the last few days says much of it – “Limited Supply, Increasing Demand: Expanding Organ Donation.” I know – it’s the age-old question in transplantation. But it remains at the epicenter of the many challenges we face as transplant surgeons.
Resource scarcity is our special burden as transplant specialists. It is truly the issue that differentiates transplantation from all other medical specialties and is the issue I focused on for both the theme for the Winter Symposium as well as the theme for my Presidency.
Working with this wonderful group made me think back in time to a place very early in my career when I was full of energy, enthusiasm and the desire to be innovative and look for a field in surgery that would allow my imagination to soar. And today, I have 2 stories to tell you. I call them collectively, “Beauty and the Beast”.
The first story, which I call “the Beauty,” took place relatively early in my residency. [I had been] invited me to spend my entire 3rd year of residency working on the transplant service in both a clinical and bench-top research capacity; it was an incredible opportunity. The combination of clinical and bench work was the epitome of translational education and clinched my interest and passion in transplant.
My bench research was investigating the combination of donor specific blood transfusions and Cyclosporine in the rat heart transplant model. My problem was mastering the heterotopic heart transplant; I think I killed most of the rats in NY! The problem was that every time I thought I was getting the hang of it, my beeper went off with an urgent clinical issue that took precedence; it was really challenging. I had just starting dating someone new a few months earlier and I had the bright idea of a really cool date; we could both go to the lab one evening. There would be peace and quiet; I might get the “interruption free zone” I needed and she could see what I was doing or more likely just read her book. What a cool guy I was… anyway she agreed!
I got through the procedure and got ready to release the clamps with a dread based on my passed 100 failures. But I took the clamps off, there was no bleeding and the heart started to beat for the first time. I let out a shriek of joy and called in my girlfriend Erica to see. She was amazed. It was a magical and exhilarating moment that we shared and fully enjoyed.
I think her support that night gave us both an enduring passion for the field and the mutual commitment to endure through the many hurdles that might come in the years ahead. And I discovered that with commitment and persistence, I could perform these heart transplants with a high rate of success that ultimately allowed for a publication in Transplantation. More importantly, I think I found my career and my wife that night!
So now for the “Beast.” After a time working and living in Pittsburgh, I returned to New York in 1986 to start-up a liver program at Mt. Sinai Hospital only to find enumerable state and local political hurdles. [But] after 18 long months, we got the necessary approvals and our young team was rarrin’ to go!
The first case was a resounding success. Lots of high fives! The second case, not so good. The liver graft didn’t function, but followed by successful re-transplant. Then our third case – another bad graft! A beautiful 18-year-old girl with severe autoimmune hepatitis. High enzymes, coagulopathy, but this time a positive cross-match. Having seen one case of hyperacute rejection in Pittsburgh, and feeling rather desperate not to re-transplant 2 of our first 3 cases, I decided on a course of immune therapy. I put on my rose colored glasses and tried to convince myself daily that things were improving…until she crashed, was resuscitated, re-transplanted too late, and died a week later of sepsis.
In that moment I saw the terrible conflict I was confronting. [On one hand,] my physicians’ duty to the patient and [on the other, my] fiduciary duty to the institution to have a program with great results that wasn’t wasting organs. But the truth was I hadn’t had the fortitude to do the courageous thing of putting my patient’s best interest first, re-transplanting her early and accepting another early graft loss. I had tried to satisfy both interests and failed miserably. It was crushing and I found myself in a back stairway crying my eyes out and re-thinking everything. I was furious with myself, scared and feeling quite alone. But stairwells get used by others and a senior surgeon came upon me and kindly spent some time listening. I actually don’t remember the substance of the conversation, but I do remember the message – just collect your thoughts, re-focus and keep moving forward, and always try to put patients first.
Thirty years later, this “Beast” of transplantation continues to haunt everything we do. So I ask you today – how can we stay true to our collective vision of “saving and improving lives with transplantation” and do the best for all of our patient’s in a scarce resource, highly regulated “battlefield triage” environment? How do we transform the Beast into the handsome Prince that Beauty eventually marries?
There are no simple answers, but I believe the root cause that differentiates us and creates so many of our problems, regulations and tribulations is organ scarcity. So what can we do?
I dream of practicing transplant surgery in a non-scarce resource environment, but this dream is no small goal. “The Beast” survives and thrives because we must deal with the complex pressures and burdens that scarce resources impart. But the goal, if achieved, has the potential to change the way we think about and practice transplantation. To address the issue of organ scarcity in a transformative fashion will take a highly coordinated approach that encompasses each of the four sectors of the ASTS strategic plan – optimal patient care, advocacy, research, and training and professional development.
Optimal Patient Care. In June, I asked Dorry Segev to lead a new task force to review issues in organ donation and access, understand the myriad of initiatives already underway, and create a Society white paper that will then inform a 5-year strategic plan on this issue. For example, the National Living Donor Assistance Center (NLDAC) is an important piece of our Optimal Patient Care strategy by helping donors avoid financial disincentives. NLDAC program has helped 2,500 recipients since it began, and saved Medicare over $60 million in dialysis costs. Most importantly, almost 75% of donors who have participated in NLDAC say they wouldn’t have been able to donate without it.
Advocacy. As I toured the country this Fall to attend UNOS Regional Meetings, the sense of PSR and CMS induced risk-aversion in candidate and organ selection was on the top of everyone’s mind. We all know what happens with flagging and the potential for SIA’s. Risk aversion flourishes; needy and deserving, but more risky patients without “good risk adjusters” go unlisted; and 4,000 organs that are procured get discarded. Program preservation begins to overtake and supersede patient care.
Through careful planning and intense diplomatic discussions with the UNOS Board, a resolution was passed that instructs the MPSC to create a group of quality metrics that are able to identify programs with only clinically relevant quality issues; and to create this plan in the next 6 months! These changes have the potential to create a climate that incentivizes the type of calculated risk-taking that promotes organ donation and utilization and improves overall patient care. We must keep the pedal to the metal so as not to lose momentum!
Research. The Institute of Medicine (IOM) study on organ donor intervention serves as a tangible example of ASTS’s tenacity. In a move of leadership, ASTS was the first organization to publicly announce a funding commitment to the study. Since then, at least six additional groups have announced support. I look forward to the deliberations of the IOM and am confident that the recommendations that emerge will provide an organizational framework and roadmap that will catalyze more coordinated research that will lead to improved quality and quantity of deceased donor organs. There is light at the end of the tunnel!
Training and Professional Development. Meetings such as the Fellows’ Symposium, ATC, the new “lap” donor course and the Winter Symposium exemplify how ASTS uses training and education to support [big goal achievement]. I am very excited to remind you that you are in for a compelling session this afternoon with our 6 former Surgeons General. [Former Surgeon General Ken Moritsugu has suggested the idea of a] national campaign to increase organ donation; a campaign with the imprimatur of the Surgeon’s General office, along the lines of the campaign to reduce smoking. I am sure what will start today will raise societal awareness of this growing public health issue and strengthen our resolve to galvanize the community around our goal and our vision to save and improve more lives through transplantation.
–to be continued–