by Bill Frist
In the United States, that would never have been tolerated. If we had one hundred patients who needed open-heart surgery, we’d work around the clock and get them all done within a week. Yes, some patients might have to wait a couple of weeks for purely elective heart surgery in the United States, but it wouldn’t be because a government bureaucrat was rationing their care based on money available or some politician’s decision to cut off the money spigot.
Another eye-opener to me was the British attitude toward the clock. Medical training in the United States was focused entirely on patient care. In those days, the hours an intern or a resident worked were always secondary to the care of the patient. If you were a resident and you had a new patient, in our U.S. surgical programs you would stay with the patient and make sure that you attended to his or her every need. There was no “punching out” at five or six o’clock. The patient was your responsibility, and you did not hand that off to others, even if it meant staying extra hours to make sure that absolutely everything for that patient was smooth.
In England, the intern-equivalents, or “house men” as they were called, working under me, with the national government their boss and the socialized system their administrator, clocked in each day, arriving not a minute before the required 7:30 A.M., and when five o’clock came around, even if we were in the middle of rounds on the patient wards, they would clock out, having fulfilled their end of their contract with the government. But what about the patient? I’d think in amazement. Well, the next shift could pick up the pieces.
In America today, because of the law that specifies residents work no more than eighty hours per week, residents are forced to watch the clock much more stringently. But my dad would never have understood “clocking in and out” when it came to taking care of patients. One’s personal experiences in life do color one’s policies and attitudes. Mine surely have.
Based on that personal experience of working directly for the British National Health Services (NHS), it seemed to me that the disadvantages far outweighed the benefits of truly socialized medicine, where the rationing of diagnostic modalities like CAT scans and MRI machines, types of treatment for cancer, availability of life-saving pharmaceutical agents, and specific number of hospital beds are all determined (and thus rationed) by some politician in government, regardless of current patient needs or medical requirements. It may just be the doctor in me, but I think the health of a person is too personal and too critical to be left to the whims of a government official, whose priorities shift from year to year, dictated by the budget cycle.
Lamenting the slowness in the system, the unavailability and inaccessibility of much of the latest useful technology, the long lines of people waiting for the heart operations that we performed every day, the inability to even offer state-of-the-art treatment for many types of cancer, and the lack of access to life-saving kidney dialysis for older people, I returned home convinced that socialized medicine could not, and should not, work in any shape or form in America.
Moreover, my experience there further developed my own philosophy on the American health-care sector—that we need to address the egregious gaps in cost and access in our health-care system, not by centralized federal government rationing but by changing the incentives within our own blended private-public system. For those unable to get insurance on their own, we need to move more toward the English concept of medicine as a “social good,” but the overwhelming majority of our health care should be delivered through a private system that centers just as Dad did on value for the individual patient that aligns incentives for doctors, nurses, hospitals, and health plans to keep people healthy or return them to health. The “sector” must be transformed into an integrated “system” that rewards quality of the entire care delivery value chain of a medical condition and that is driven by twenty-first-century knowledge and interconnected information systems. Consumers and participants should be the drivers for quality, and basic health-care services should be available and affordable to every American. I hope, in the years to come, we’ll be able to move our system much closer to this ideal that centers on value without losing any of the wonderful benefits of choice and high quality provided by our current system.
THOUGH WE NEVER GOT THAT ROSE-COVERED COTTAGE, KARYN and I loved our experience in Southampton; we grew closer and the joy of our life (the first of three), Harrison, arrived. I gained a more complete and much richer understanding of my own specialty of heart and lung surgery, as well as an appreciation for both the unique contribution of innovation that characterizes American medicine and of the freedoms we have in America to choose our own doctors and our own health-care plans. My time in Southampton also reminded me of the dichotomy regarding the two disparate passions with which I lived perpetually: I wanted to work hard to become a pioneering, cutting-edge surgeon who was part of figuring out innovative treatments for the really big challenges and unknowns in cancer and heart disease, who had access to the breathtaking new advances and technologies to bring hope and life to others, without losing that personal, compassionate, patient-centered, family-doctor approach to healing that my dad had modeled so well.
Better yet, I’d heard about a place and a doctor who might be able to help me bring these two seemingly conflicting passions together—a place and a doctor who embodied the passions of health, hope, and healing.
6
The Heart of the Matter
Being on the cutting edge and creating new knowledge always appealed to me. It probably didn’t start in Dr. Powell’s basic science lab at the MGH, but it certainly was cultivated there.
Even while doing heart and lung surgery in England, I had already taken an interest in, and started gravitating toward, the exciting new frontier of transplanting the human heart—a field with almost science-fiction-like opportunities to treat individuals bound by diseases that otherwise would be fatal. Transplantation also appealed to my passion for innovative solutions to seemingly unsolvable problems.
Ironically, in the early 1980s, Mass General, despite being one of the most advanced, highly respected hospitals in the country and being located in the very city where kidney transplantation had started some twenty-five years earlier, was not yet convinced that the risks of heart transplantation outweighed the benefits. Conventional wisdom among the physicians there was that heart transplantation wouldn’t work, at least in the short term; the immunological rejection and enveloping infections made it impractical and too expensive. So, in 1980 the medical institutions and bureaucracy in Boston formally said no to the pursuit of transplanting the human heart. A moratorium on heart transplantation was announced.
This was devastating news for me. How shortsighted! How could the best of the best refuse to participate in one of the most promising new breakthroughs of the past fifty years? In effect, they were signing my traveling papers.
I immediately began searching for the most progressive, pioneering transplant program in the world. I found it at Stanford University Medical Center in Palo Alto, California, under the direction of Dr. Norman Shumway, the true father of heart transplantation.
Shumway and his associates had been working on animal heart transplants since the 1950s. In December 1959, Dr. Shumway and his close friend and medical research collaborator, Dr. Richard Lower, successfully transplanted a heart between two dogs. The dog with the transplanted heart lived for eight days, proving Shumway’s theories and procedures could work.
Both doctors believed it was only a matter of time before human heart transplantation could be done, but Shumway and Lower also believed in careful, meticulous research. Through rigorous, cautious exploration and surgical precision, they proceeded, step by step, through the early 1960s.
With Shumway’s blessing and recommendation, Lower left Stanford in 1965 to head his own surgical team at the Medical College of Virginia in Richmond. The two men stayed in contact and continued a friendly competition in the race to see who could be the first to do an actual human heart transplant. Meanwhil
e, two far more intense rivals, Dr. Adrian Kantrowitz at Maimonides Hospital in Brooklyn and Dr. Christiaan Barnard in Cape Town, South Africa, also hoped to become the world’s first successful human heart transplant surgeon. The global race had begun.
All four surgeons knew and had a grudging respect for one another. Barnard and Shumway, however, were cut from radically different cloth. Barnard’s ambitious, hard-charging personality had grated against Shumway’s more laconic, laid-back personality when they’d worked together briefly on a surgical team in Minnesota in the mid-1950s. While Shumway preferred a team effort, graciously sharing any praise or acclaim for his accomplishments with the nurses, doctors, technicians, and scientists around him, Barnard seemed obsessed with achieving fame and glory for himself.
Over an eight-year period, Shumway and Lower had also systematically done extensive basic science research. After developing the surgical techniques of removing and replacing the heart, they turned their attention to the next challenge—the response of the body’s immune system to reject foreign organs, even those implanted by well-meaning surgeons. Meanwhile, Barnard, who had done relatively little fundamental transplant research, had spent a mere three months in Richmond with Dr. Lower, carefully observing his research and techniques and planning to replicate them back in South Africa.
Shumway wisely recognized that he also needed the American public to become comfortable with the novel idea of transplanting a human heart. Two issues had to be resolved. One was the medical and ethical question of when a person was actually dead, making the removal of a heart to be used in another person’s body acceptable. At that time, simple absence of a heartbeat was the accepted definition of death. The concept of brain death had not yet entered American law or understanding. The heart, rather than the brain, was regarded as the defining organ of life.
The other challenge was the romantic and spiritual concept of the heart as the center of a person’s being. Nobody ever sent a valentine saying, “I love you with all my liver.” For the average person in those days, to remove a person’s heart was to take away his or her core identity.
Slowly, both of these obstacles were overcome through educational efforts and scientific research, even as Shumway systematically continued to prepare the way technically and scientifically for heart transplantation. By November 20, 1967, Shumway and his brilliant young chief resident, Ed Stinson, felt confident enough in attempting a human heart transplant that they announced their intentions in the prestigious Journal of the American Medical Association (JAMA). Of course, for that to happen, someone had to die without damaging the heart, and an amazing number of coincidences had to align themselves. So Shumway and Stinson waited patiently for the moment to act.
Meanwhile, on December 3, 1967, in Cape Town, Dr. Christiaan Barnard used the Shumway and Lower techniques to transplant a human heart from a young woman, brain-dead after a car accident, into the body of a fifty-five-year-old grocer, Louis Washkansky. Barnard won the race to transplant a human heart from one human being to another.
The world hailed Barnard’s success, catapulting the Afrikaner to instant fame and acclaim. I vividly remember as a young fifteen-year-old seeing Washkansky’s and Barnard’s picture on the cover of Life magazine. Most within the scientific community who knew how Barnard had achieved his goal were less enthralled. They felt that because of their more than a decade of painstaking and disciplined basic science and clinical research, it should have been Shumway or Lower who had the honor of performing the first human heart transplant, not some opportunist who had stolen the glory from them.
Ever gracious, Norman Shumway publicly spoke kindly and magnanimously of Barnard, allowing only Ed Stinson to share his private anguish and disappointment. Nevertheless, he was committed to moving forward with his intention to transplant a human heart at Stanford, hoping for the right combination of a needy recipient and an appropriate donor. Shumway felt that with Barnard attracting the lion’s share of the media’s attention, he and Stinson could quietly go about their business, perfecting the procedures and saving lives by means of heart transplantation.
The following day, David McIntire Bashaw was born in Philadelphia to Celeste and Keith Bashaw. Celeste was the daughter of Reverend Carl McIntire, a prominent Presbyterian minister and one of America’s most loved and respected radio Bible teachers. There was little rejoicing in the Christian community, however. The famous preacher’s grandson, David, was an anencephalic baby—born without a functioning brain and leaking bloody cerebral spinal fluid. Yet the infant’s heart continued to beat strongly. With the permission of Celeste and Keith, their baby was flown to Brooklyn, where Dr. Adrian Kantrowitz waited in anticipation of attempting America’s first heart transplant, an even more delicate procedure because Kantrowitz hoped to transplant baby David’s heart into the body of a seventeen-day-old baby boy, Jamie Scudero, who was dying of congestive heart failure.
At five-thirty the following morning, Kantrowitz attempted to become the first American to transplant a human heart. But seven hours after the procedure, the heart stopped and both little David and little Jamie were dead.
Then, a mere eighteen days after performing the first human heart transplant, Christiaan Barnard watched as his patient, Louis Washkansky, turned a blue-black color and died. His immune system had rejected the young woman’s heart.
Undeterred and no less confident, Shumway and Stinson performed the first successful heart transplant in America a month later, on January 6, 1968, when they transplanted the heart of Virginia White, a forty-three-year-old wife and mother of two, who had suffered a brain hemorrhage, into the body of Mike Kasperak, a fifty-four-year-old retired steelworker.
Kasperak lived for fourteen days before succumbing to multiple system failures, none of which was related to his new heart’s ability to pump blood through his system, or his body’s rejection of the new heart. Shumway and Stinson, though saddened and exhausted after several operations trying to repair Kasperak’s debilitated body, were encouraged that the transplanted heart had continued to function through it all. A new world had opened before them.
Over the next year, heart transplants became the “designer” operation, as high-profile cardiac surgeons around the world rushed to attempt the new procedures. Shumway knew that most of these would fail, and indeed some 85 percent of the patients died relatively soon after transplantation. Only Shumway himself could boast of better results, managing to keep about 40 percent of his patients alive. Most surgeons quickly abandoned the procedure. But not Shumway. He knew the path to success: focus, systematic research, hard work, and never saying “It can’t be done.” He continued his systematic and deliberate approach of steady research to address each new problem that appeared along the way. When everyone was giving up because there was no way to diagnose rejection early in its course, Shumway did what any great scientist would do; he solved the new problem. He figured out a way to sample a tiny piece of heart muscle and make the diagnosis before the heart had irreversible damage. The tool to do the sampling, the cardiac bioptome, was a Stanford invention.
The next problem to rear its head was the infections that arose in the recipient, whose immune system was suppressed by medicine to prevent rejection of the organ. Solving this problem required a new medicine. It was not until the drug cyclosporine began to be used experimentally in 1980 that the odds of long-term success began to shift in Shumway’s favor. Cyclosporine suppressed the immune system of the transplant recipient enough to keep the body from rejecting the new heart, yet amazingly, the drug left the rest of the immune system capable of preventing most infections. Shumway started using the new drug, and soon his patients were not only surviving for a year or more, but with the help of cyclosporine, many went on to live long and productive lives.
Cyclosporine use was still in its early stages when I traveled again to Stanford in the early 1980s. I had met Dr. Shumway a number of years earlier when I was considering going to Stanford for medical school. Shumway, whom I’d re
ad about since I was a teenager, and whose systematic and deliberate approach to achieve great things had become legendary, surprised and impressed me with his easygoing, relaxed demeanor. I couldn’t help but contrast the purposely intense and too frequently humiliating atmosphere of most cardiac surgical training programs with the equally demanding but laid-back and respectful and encouraging attitudes of Dr. Shumway and his team in California.
I kept in touch with Dr. Shumway, letting him know of my interest in heart transplantation. One day, in the middle of my thoracic chief residency at the MGH, I received the call: “Bill, in six months I’ll have an opening in the heart transplant program here. I want you to come to be the senior fellow, then chief resident.”
I was ecstatic. I called Karyn and told her the great news. After a few days of discussion, we decided we should leave the security of a career in Boston, apparently locked in its backward-looking ways when it came to heart and lung transplantation, to go work with the visionary Shumway. Boston killed the dream, but Shumway was making dreams become reality.
I quickly discovered that Shumway’s team was an eclectic bunch of unusual personalities, each person brilliant in his or her own way. That was part of the genius of Shumway; he spotted talents instinctively and promoted them, often overlooking quiddities and frailties, or maybe even playfully delighting in them. One of the first oddities I noticed upon my arrival in Palo Alto was that every single member of the cardiac surgical team, except Shumway himself, wore cowboy boots. I had no idea what significance the boots implied, whether a rugged toughness or nonconformity to medical norms, but I soon dug out an old pair of boots that I hadn’t worn since my teenage years. The irony was not lost on me that having been raised in Nashville, home of country music and the Grand Ole Opry, I had to move to California to wear cowboy boots every day.