2000 Presidential Address
Delivered on Tuesday, May 16, 2000 during Transplant 2000 by AST President, Dr. John R. Lake, MD, Sheraton Chicago Hotel and Towers, Chicago, Illinois
I want to begin by thanking each and every member of this society for the opportunity you presented me this year, to preside over a wonderful and dynamic group of transplant professionals. It truly has been my privilege and an honor to serve. A wise man once said that the key to good leadership is the ability to understand the needs of those whom you lead. This has been my mantra this year. I hope that you all feel the leadership of the AST has focused the efforts of our society on your needs.
The radio personality, Garrison Keillor, has a segment on his weekly radio show that he calls "The News from Lake Woebegone." Lake Woebegone, as some of you know, is a fictional Hamlet in the middle of Minnesota. The people who reside in this town reflect the composition of most towns in rural Minnesota, typically Scandinavian, religious, morally conservative and in some way tied to agri-business. They are not the type of people you would regard as funny, certainly not trend-setting and most would believe uninteresting. The "News From Lake Woebegone" is generally a recitation of the events that occurred during the past week, with Mr. Keillor expounding on a couple of the more interesting events. While much of the life in Lake Woebegone would seem on the surface, mundane and common, it's his ability to make their lives sound unique and exciting that creates the popularity for his radio show. In many ways, my address here today will be much like "The News from Lake Wobegone," a review of the events from the past year, much of it will seem mundane and common. But hopefully, I can add some spice to the recounting of a few events.
It has been an interesting year in the AST. I believe we had mostly highs, but a few lows and overall I think we have accomplished much. When I accepted the call to the presidency of this society, I sought counsel from a colleague who was just finishing his tenure as President of the American Society for Clinical Investigation. I asked what he thought was important in leading a society and he responded, "Don't screw it up." He went on to say that you won't screw it up if you keep your initiatives few, selecting those that were relatively likely to succeed. I hope to convince you in the next few minutes that I haven't screwed it up and that we actually are stronger as a society than we have ever been.
Our mission statement reads, "The American Society of Transplantation is an organization of transplant professionals dedicated to research, education, advocacy and patient care in transplantation science and medicine. Through the work of the AST, the transfer of information from the basic science laboratories to the transplant clinics will ultimately lead to new scientific advances and improvements in patient care." I will address each of these missions.
First, with regard to patient care, our society has been active in several ways. This year, we sponsored two additional consensus-like conferences. One on withdrawal of cortico-steroids and the second on post transplant lymphoproliferative disorders. Both of these conferences were extremely successful, the discussion was quite lively and the proceedings from these meetings are being prepared and will be submitted for publication. I also want to bring your attention to a very important conference that will occur in Kansas City the first Thursday and Friday in June. This will be a conference on living donor organ transplantation. We are co-sponsoring this with the ASTS and the National Kidney Foundation. This is extremely timely as it should be apparent from this meeting that the recent growth of live donor transplants has been impressive, particularly for the extra renal organs. I want to commend the planning committee, and in particular, John Davis from the NKF, Charlie Miller from the ASTS and Frank Delmonico from our society for developing what will be an outstanding program. I believe we will learn much at this conference. And hopefully, the conference will lay the groundwork for new initiatives to determine how to optimally select and utilize live donors for transplantation.
One of our greatest challenges in patient care is to train the next generation of transplant professionals. I regard transplantation as one of the most exciting fields of medicine. However, the late 90s have not been kind to medical specialties, with decreasing numbers and quality of applicants for subspecialty training positions. In some cases, this was the result of misguided manpower studies, particularly in my field of Gastroenterology and Hepatology. Consequently, we now find ourselves with shortages of subspecialists and this translates into a smaller pool of future transplant physicians and scientists. The leadership of your society has established as a high priority, increasing the number of people being trained in transplant medicine and science. We are very excited that the first graduates of AST/ASN certified renal transplant training programs will complete their programs this year. However, this is not enough. We must focus on identifying the future generation of transplant professionals at relatively early stages in their training. At this meeting, we have sponsored 93 fellows from all disciplines, including nephrology, hepatology, cardiology, pulmonology and surgery to attend our meeting. Here, they have interacted with professionals in the field, witnessed first hand the exciting basic and clinical science this field has to offer and hopefully we can convince them there is no better career than as a transplant physician, scientist or surgeon.
We hope to attract even a larger number of trainees next year, and the goal is to identify trainees at a stage of their career before they have differentiated. We are indebted to our pharmaceutical partners who have supported this project and allowed us to pilot this program. However, we can't stop here. We need to continue to work to attract first-rate young investigators, clinical scientists and clinicians to our field and into our society. We must identify novel programs that will allow us to do so. We also must continue to be advocates for graduate medical education and continue to work in Washington to make certain that GME funding is preserved for the subspecialties.
We also enjoyed success in the area of research. Through our advocacy in Washington, we are able to assist in keeping the Federal government on track towards the goal of doubling the NIH budget in five years. Also as a society, we have increased our direct financial support of research by 35% in the past year, increasing both the number of research grants as well as increasing the size of the awards to parallel what the NIH has done. We also continue to work with other organizations such as the JDF, National Kidney Foundation and National Institutes of Health to sponsor important transplantation research. All of us are extremely proud and excited by the prospects of the Tolerance Network, currently being sponsored by NAIAD and hopefully with additional sponsorship coming from other institutes in the future. The Tolerance Network will not only sponsor basic research into the mechanisms of tolerance, but importantly is geared towards developing clinical protocols that will make tolerance a reality.
It could be argued, the thing our society does best is education and we have continued to strive for excellence in all of our educational programs. Clearly as evidenced by all of you here, this meeting is the premier transplant meeting. Our ability to partner with the ASTS has brought this meeting to a new level. The attendance of nearly 3800 is striking. The quality of the science and the clinical research being presented here is truly outstanding. The challenge we now have is how to manage this growth so that we don't lose the advantages of the smaller meeting; that being the ability to interact easily with our colleagues, and to be exposed to all types of transplantation research, not just the research which is germane to our special niches. We also need to nurture our international colleagues. This is truly an international meeting with many of the best presentations coming from outside North America. We have clearly outgrown the Sheraton. While we are committed to one more year here, at that point we will need to move to additional venues which will include Washington DC in 2002 and 2003, Boston in 2004 and Seattle in 2005.
Our Fellow's Symposium, that has been so successful under the leadership of Les Miller, was also changed this year. Last year, Education Committee identified the need for an update course in transplantation medicine for clinicians, who either have just joined the field or for those who might want a clinical update. Last years meeting, which was held for the first time outside of the United States in Toronto, I believe achieved these goals. The verbal feedback we received from the participants was very good and this remains a program that we continue to work on to serve the needs of fellows and practicing physicians alike. This year, we will return to the format of a Fellow's Symposium, but with a much smaller faculty and with increased faculty/fellow interaction.
This year's Winter Symposium in Puerto Rico was also a great success. The scientific program put together by Drs. Sue McDiarmid and Phil Halloran on the early events after transplant and their impact on outcomes, was first-rate and extremely well received. The venue in Puerto Rico was beautiful, but serious questions have been raised by many as to the appropriateness of such lavishness. This meeting is intended to be an opportunity for a small group of seasoned transplant professionals to examine, in depth, relatively focused issues in transplantation. Our challenge now is to keep the meeting small without using high resort costs to do so. I also strongly believe whatever mechanism we use also to limit the size of this meeting, it must not do so by only excluding our more junior colleagues.
A major step forward in our educational activities was when we received approval from the ACCME to provide continuing medical education credits for physicians. We have now been re-reviewed by ACCME and are now fully accredited. While we have done well in all the reviews, this has been a learning process.
We, as a society, are extremely skilled in putting on high quality symposia and can always call upon our members to deliver first-rate presentations. However, there are innumerable other activities for which we could provide CME credit. Many of these are activities that our society has not previously sponsored.
Our society was recently approached by Wyeth-Ayerst about a multi-faceted program regarding TOR inhibitors. There were three main activities that were part of this proposal, including a satellite symposium at the ASN meeting, production of a high quality slide set on both basic and clinical aspects of TOR inhibitors and finally, preparation of a resource guide that would accompany the slide kit. All members of both societies should have received the slide set and resource guide, and I am sure that you would agree it is a high quality product free of industry bias. The slide set was reviewed and ultimately approved by the Education Committee of the AST. The members of the Education Committee, however, questioned the process in general as to how CME special projects should be developed and the role of the Education Committee in reviewing such activities.
The issues as to how the AST should handle such CME special projects include 1) what should be the role of the Education Committee in developing and ultimately approving such activities? 2) What sort of reimbursement should the AST receive for accrediting these activities? 3) Who is responsible for developing contracts between the AST and outside agencies that want CME accreditation? 4) What kinds of limits, if any, should be placed on CME special projects?
These issues have been discussed extensively by the Education and Executive Committees of the AST and was addressed by the Board Saturday. We have made several changes to address these issues. They include: 1) establishing a formal policy and standardizing honoraria paid for AST sponsored educational activities. 2) possibly expanding the education committee to adequately deal with new educational initiatives. 3) assuring the Board has control of the financial aspects of all CME accreditation projects. 4) reorganizing, internally, our CME administration.
Our CME activities will be coordinated by Ms. Nicolette Zuecca together with our Executive Director, Ms. Susan Nelson. Dr. Floyd Pennington has been retained by AST to serve as an educational consultant to the Executive Director, the AST Board and the AST Education Committee. Dr. Pennington has twenty years of experience in executive and educational leadership in medical schools, medically related associations, professional societies and medical communication companies. Dr. Pennington will review current AST educational programs and processes, advise the AST about enhancing current programs, and creating new programs and services based upon member and community need. We believe this will strengthen our CME administration.
Finally, we are also developing a formal policy for conflict of interest. This policy will be applied to all activities of the AST, including committee functions, board functions as well as educational activities.
It is in the area of advocacy that I think we have had our greatest success this year. We began the year by changing government relations firms. We enjoyed our relationship with Smith Bucklin for the preceding two years, but the cornerstone of that relationship was Mr. Bill Applegate, who served as our primary government relations person. It was Bill's move to law firm Arent Fox that prompted our reconsideration of government relations firms. After careful consideration by the Board, it was decided to go ahead and make the change to Arent Fox. As things have evolved, this was clearly the right decision. Arent Fox has given us access in Washington of which we previously could have only dreamed. In addition, Bill has continued to be a tireless advocate for the AST on Capitol Hill. Our influence on legislation has never been greater. I cannot thank Bill enough for his efforts on our behalf. Our advocacy activities are too numerous to mention them all but I want to highlight three.
First, a bill was passed this year increasing the leave that federal employees can take following live organ donation to 6 weeks. We hope this legislation, sponsored by Representative Elijah Cummings, will ultimately prove important in promoting live donor transplants. We hope that all of you will work with your local governments to see that others enjoy the same benefits that federal employees do, in terms of time required to recuperate from organ donation.
Second, our society played an important role in expanding immunosuppressive drug coverage this year. Moreover, we continue to work with a number of offices on Capitol Hill to achieve our ultimate goal of lifelong immunosuppressive drug coverage for Medicare beneficiaries.
Finally, I also believe that we have finally begun to make progress on the issue that has so troubled the transplant community; that is oversight of the OPTN by the Department of Health and Human Services. This issue has created unfortunate divisiveness in our community and has pitted transplant professional against transplant professional, program against program, state against state. It has spawned the development of splinter organizations within the field to advocate for specific positions regarding this issue. What truly has been lacking, until recently, is any interest in compromise by the various protagonists on this very troublesome issue. Our society has tried to strike a middle ground with the positions that we've advocated, trying to reflect the views of most members of our diverse society. We advocated that the government does have a right to oversee the OPTN contractor. That having been said, we completely agree with what Ron Busuttil statement on Sunday morning, "transplant professionals must set medical policy". As part of the oversight process, the secretary of DHHS should have the ability to review and comment on OPTN policies. However, any influence on medical policy must be accomplished through him or her working with transplant professionals.
Finally, it is important that we continue to reevaluate our policies of organ allocation and distribution and work towards policies that meet the needs of all transplant patients in the United States. Laws that set up boundaries to the sharing of life-saving organs do not serve the best interest of the transplant patients, nor do I believe they reflect the intent of those who selfishly offer the gift of life.
I know this firsthand from my own experience, this year, when my father passed away in Arizona. He was a lifelong resident of Minnesota. It never occurred to me nor any member of my family, that his organs should go first to someone from the state of Minnesota. However, even more preposterous was the idea that by their current state law, his organs could only be offered to someone waiting in Arizona.
My plea today is that all members of the transplant community stop the rhetoric and come together to develop a compromise that can bring this ugliest chapter in the history of transplantation in America to an end. In this regard, I stand together with Ron Busuttil to strongly support the bill to reauthorize NOTA that has been crafted by Senators Frist and Kennedy. This bill is something that accomplishes the goals that I laid out earlier. In fact, this bill largely represents the positions that Dr. Busuttil and I prosecuted during our four meetings with representatives of the DHHS. I certainly hope our successors, Dr. Sayegh and Dr. Ascher can say, next year at their presidential addresses, that this issue has been resolved.
One of the first issues that I tackled when I assumed the presidency of the AST was to examine how our society is governed. Our society has grown immensely over the past five to six years from a society largely composed of transplant nephrologists a large professional society reflecting a rather diverse membership of nephrologists, scientists, cardiologists, pulmonologists, hepatologists, surgeons and infectious disease specialists. In the past, our Board has been largely consumed with the operations of the society. However, our Society is now too large and the projects that we are involved are too many, for this organization to be entirely run by a handful of individuals. It was clear to me, and others, that in order for the Society to fulfill its goals, we were going to have to change the way the Society was governed. Thus, the board, along with several past presidents, held a strategic planning session, last July, in Minneapolis. This was a very useful process in that it set up the mechanisms by which the board could focus on strategic issues, rather than to only reacting to day to day events. We set goals for ourselves and the metrics by which we can determine whether we are meeting these goals.
Still, the Society needs to run on a day by day basis. In order to accomplish this, it is now more important than ever to have a strong committee structure. The membership of the society is empowered through the committees. It's the way the membership becomes involved in the operations of the society. It also expands the number of people contributing to the leadership of the society and hopefully generates new ideas as well as develops future board members. This past year, we've had some outstanding committees and excellent committee chairs who have accomplished a great deal. Hopefully as time goes on, this leadership strategy will continue to evolve with the committees taking on increasing responsibilities and the board primarily providing strategic leadership.
I would also like to comment on the relationship between our two great societies, the AST and ASTS. I would venture to say that at last year's meeting the relationship between the AST and the ASTS had never been worse. We had come off a year of attempting to merge the two into a single society and we arguably made every mistake one could make in this process. Rather than attempting to determine whether we had a common vision from which a new single society could evolve, we attempted to first deal with the legislative issues, which only created disputes that escalated into hard feelings between the leaderships of the two societies. However, two critical events happened at last May's Joint Council Meeting that changed our relationship. The first was the decision to work together to develop an official journal for both societies. The journal we chose to represent both societies was Transplantation but the editors turned down our offer. Only after this, did we decide to work together on a new journal that would be the official publication of both societies.
Today, I am pleased to stand before you and tell you that this journal is a reality. We selected Dr. Phil Halloran to be the first editor of the American Journal of Transplantation and, Dr. Halloran is organizing an editorial staff made up of some of the premier basic and clinical scientists in transplantation from all over the world. This will not just be a North American journal, but rather it will be an international journal, hopefully attracting the very best transplantation science, high quality reviews and commentaries from throughout the world. I have no doubt that this journal will become in short order, the premier journal in transplantation throughout the world and we are truly looking forward to its first issue which we anticipate will be published in January/February of 2001.
The second event that occurred at last year's meeting was the decision by the two societies to approach the issue of forming a new society in a thoughtful and measured way. As a first step, we hired a private consulting group to examine both organizations and determine whether forming a single society was indeed feasible. The Forbes Group concluded that the feasibility of the AST and ASTS coming together to form a single new society was possible and yet not possible. In fact, the report was a severe indictment of the leadership of both societies. It clearly identified that there was much to be gained by the two organizations forming a single society, so one could speak with a single voice in Washington, collaborate on educational programs and ultimately best serve the interests of transplant recipients. At the same time, they concluded that unless the leaders of both societies were willing to leave behind their personal agendas and avoid petty power struggles and rather focus on what was best for the members of both societies, a single new society would never become a reality. They also laid out a series of steps to follow to work towards a single society.
Both the ASTS and the AST boards accepted the findings of the Forbes report and agreed to follow their recommended steps towards a single new society. In fact, we will begin soon a comprehensive survey of both memberships to identify whether both the members of both societies share a common vision for how a new society could best serve the field of transplantation. If indeed we do have a common vision, this will form the basis for a joint strategic planning session, this fall or winter, to see whether we can expand and develop this common vision into the framework for a new society serving transplant professionals in North America. I remain convinced, the entire field of transplantation will be optimally served by a single society and I will continue to work towards that goal.
I want to close with some thoughts about the future of subspecialty societies including our own. I am concerned about a rather ominous trend in academic medicine that I think will begin having severe negative consequences towards subspecialty societies. That is the concept I call "We Eat What We Kill". As a division chief and program director, I know firsthand how budgets are currently constructed and how reimbursement is provided to individuals in academic medicine. One must clearly account for almost every moment of time and no longer are there the opportunities for nonreimbursable activities such as volunteering for subspecialty organizations. Many of us who elect to take on significant leadership roles in these societies find ourselves at risk for pay cuts because we aren't providing an adequate amount of clinical service.
I would like to believe that this trend will not continue, but I am not naïve. It will be a shame if academic health centers cannot recognize the importance of subspecialty societies in the dissemination of research and the providing of education. I fear this is going to most affect the young members in our society. Already, I think we are beginning to see the impact of this.
This phenomenon is also going to have an impact on research. Much of the research that is presented at this and other meetings is unfunded. Research that comes from a simple clinical observation with follow up studies to test the developed hypothesis. In this current environment, one is going to find it more and more difficult to perform unfunded research. I don't come before you with any answers as to how we can overcome this trend and how subspecialty societies will be able to maintain a steady flow of young and talented leaders. It is clear that we are not going to be able to afford to go beyond the volunteer leadership of our societies and it is conceivable that only when a lack of leadership reaches crisis proportions, changes will be made.
In closing, I would like to thank publicly a number of people whose support has been invaluable. I first would like to thank my wife Mamiko and my three beautiful daughters Katrina, Natalie and Chelsea, who bring extraordinary joy to my life. Mamiko not only tolerated my absences this past year, but has always provided me with unconditional love and support. I'd like to thank the members of the Board of Directors of the AST. One could not have hoped for a more effective leadership group with whom to work. I'd also like to thank our committee chairs for the past year for the leadership that they have provided.
I especially want to thank the staff at Association Headquarters and in particular our Executive Director, Susan Nelson. Susan is truly the person who keeps the society on the right track year after year. She is clearly one of the reasons why our society has achieved as much as it has. I would also like to thank the other members of Susan's staff from Association Headquarters, in particular, Nikki Zuecca and Beth Jenkins. I thank Pam Ballinger, who continues to run the best meeting in the country and the rest of the Transplant 2000 staff.
Finally, I would like to thank Ron Busuttil for his friendship and leadership this past year. I believe that Ron and I have developed a model relationship for our two societies. Ron and I are different people and we did not agree on everything. But, rather than focusing on any differences, we focused on developing common principles and a common vision. Most importantly, we communicated freely and frequently. Issues were never allowed to fester, but rather were immediately addressed and almost invariably resolved with agreement. This must be the model by which our societies continue to work together. I close with an admonition to the future leaders of both societies, "Don't screw it up".