Stop Handing Me Boxes

2016 American Society of Transplantation Presidential Address - James S. Allan, MD, MBA

It’s been an absolute honor to serve as the President of the AST over the past year, and I want to extend my sincere thanks to all of the board members, COP & committee leaders, and staff who have worked so hard to make our society great.  I also want to thank my colleagues and my family for supporting me throughout this presidency.  While I have been at the hospital or travelling on business, my wife, Susan, has managed to raise two wonderful children, all the while managing to hold down her own demanding full-time job. My children, Sara and James, have also been a huge support and inspiration to me, and I couldn’t be any prouder of both of them.

When I arrived at college in 1982, the first assignment that I was given was to read a book by an author named Thomas Kuhn. The book was entitled The Structure of Scientific Revolutions. Thomas Kuhn obtained undergraduate and graduate degrees in physics from Harvard and initially conceived of this book after having been asked to teach a history of science course during a three-year post-doctoral fellowship at Harvard. Ultimately published in 1962, this monograph is perhaps the most influential modern philosophical work on the progress of science.

The essence of Kuhn’s thesis is that science progresses in a cyclical fashion. First comes a period of what Kuhn has termed as "normal science." Normal science can be thought of as the slow, methodical work that most of us do every day. It is through this process that we either add another brick to the wall that supports a current theory; or, conversely, that we chip away at this wall, as we discover flaws and inconsistencies in the currently accepted model. Ultimately, enough incongruities and complexities in a previously accepted theory are revealed, and a crisis of confidence will occur.

It is at this point that science has the opportunity to progress significantly, as the original set of theories and postulates are rejected, and a new paradigm is created. Kuhn referred to this event as the "paradigm shift," and he is singularly responsible for the introduction of this term into our lexicon, almost to the point of triteness some half century later. We have seen these paradigm shifts many times in the past. In the Copernican Revolution, Ptolemy’s model of the geocentric solar system was rejected in favor of a simpler heliocentric model. Einstein developed quantum theory to explain the photoelectric effect, for which he was awarded the Nobel Prize. He also taught us that the most constant thing in our everyday lives, time itself, was not at all constant—a theory that was empirically proved when an atomic clock was  flown around the world, returning to earth showing a different time than a second earthbound clock to which it had been synchronized.

Unfortunately, most of us will never receive the fame or accolades of Copernicus or Einstein, but take some comfort in knowing that the everyday work that we all do is the enabler for the occasional paradigm shift. Einstein’s success would not have been possible, if it weren’t for the results of an ordinary experiment performed a few years before by Max Planck. Copernicus’s transformative vision of the universe would not have been possible, if it were not for previous work done by two Islamic astronomers whose names are probably not known by the majority of the people in this room. Just as Pasteur said that "chance favors the prepared mind," the paradigm shift only occurs when the rest of us prepare the playing field for the star athlete.

So where are the opportunities for paradigm shifts in transplantation?  One only needs to look at the current problems and limitations in our field to see what needs to be done. Transplantation faces two major obstacles.  First, our current paradigm of immunosuppressive therapy results in organ rejection, opportunistic infections, malignancies, and drug toxicities. The paradigm shift that will address this issue, and one that is occurring now, is that of tolerance induction.

Second, our current paradigm of altruistic organ donation does not yield sufficient numbers of suitable organs to meet the growing demand for transplantation. Solutions to this problem are multifold. First, our burgeoning ability to modify the genome and humanize a xenograft could potentially allow us to have an unlimited supply of standardized off-the-shelf organs for immediate transplantation. Second, as our ability to control the differentiation of stem cells improves, de novo organ regeneration may be able to fill the need for transplantable organs. Third, progress in the technologies that underlie mechanical support devices may advance sufficiently that such support will offer acceptable destination therapy to patients with end-stage organ disease. Fourth, the removal of financial impediments to living donation and the provision of regulated financial incentives may provide the impetus for increased living donation in a way that does not diminish human dignity, autonomy, and social justice.

I would be remiss if I did not mention here the bold step that United Healthcare and OPTUM announced yesterday to cover travel-related expenses for living donors serving their insured patients. I am now calling on all private insurers to join Untied Healthcare and OPTUM immediately in providing similar benefits.

These are the paradigm shifts that we will recognize a half century from now. However, the conceptualization of grand plans is easy, but making these transformative ideas a reality is much more difficult.

To this end, our field faces many challenges. First, our research is grossly underfunded. Today, members of our leadership team have taken a day-trip to Washington to participate in the White House summit intended to put a spotlight on transplantation. I have asked our hosts at the White House for a number of deliverables, including increased funding for research and a fully dedicated NIH study section to adjudicate grants in our field. Our second major challenge is that we have no nationwide system to conduct coordinated donor research. The AST in conjunction with the ASTS is leading an effort to resolve this deficiency, but will need support at the national level for this to occur. Third, our field is horribly over-regulated. Our pharmaceutical partners have difficulty bringing drugs to market, and lose much of their patent protection in the course of performing years of trials with regulatorily-mandated endpoints that are inappropriate. Similarly, our centers are burdened with the yoke of metrics that cause disruptive behavior, rather than promote high-quality, cost-effective care. We are grateful for recent support of a major initiative to examine and realign the metrics by which our performance is judged, but again, we will need a willingness at a national level to roll back regulation, if this goal is ever to come to fruition.

As professionals, we are constantly exhorted to "think outside the box." We are told that creative, unfettered thinking is what we need to achieve our own paradigm shifts. But, the reality in which we practice is very different. Quite simply, if you want me to think outside of the box, you need to quit handing me boxes!

When I wrote my first blog as president, I characterized the AST as strong and relevant. Thanks to the combined efforts of the many people gathered here, the AST has had a banner year. Our membership is at a record high, we are debt-free with $15M in liquid assets. The AST has an endowment that that provides the society nearly a half-million dollars in annual operating income, without consumption of the corpus of this fund. Our winter meeting was a spectacular success. We have also had the best year in nearly a decade with respect to fundraising, and internal philanthropy from our members has doubled in the past year. This year, we have been able to provide $1.3 million in research grants. Most importantly, however, the AST is performing actively and with strategic consistency on every aspect of our mission.

Over the next few years, you will see the AST transition to a more public facing organization. This paradigm shift in our society will allow us to leverage public support in our efforts to advocate for our field and to provide increased research and educational opportunities for our membership. Our logo and webpage redesign, our incipient efforts in the cause marketing arena, and the relationships that we have been recently building with patients and patient organizations are just first steps in this strategic transformation of our society. I have no doubt that this transition will be challenging, but I have every confidence that the people in this room can do it, especially when we work together.

It has been a privilege to have had the opportunity to serve as President of the AST, and I am forever grateful for your support.