Flavio Vincenti, MD 2008 Presidential Address
Thank you Jeff for that gracious introduction and for your support and counsel over the past year.
Dear AST members and friends:
I would like to begin by thanking the members of our Society for the honor of electing me to the Presidency of the AST a year ago. This has been a very busy year. Today, a year later, I am here to give an account to you of what this Society has accomplished over the past year, as well as share reflections on what the future may hold for us, and relate my own journey as a transplant nephrologist. In order to add some levity to my presentation, I’ll also contribute my philosophy on how to succeed as a transplant physician and, equally as important, my personal recipe on how to find balance and happiness while pursuing one’s goals in life. Some of us know that presidential speeches of the past were not the more popular feature of the ATC program, and so I have endeavored to inject PowerPoint humor into occasionally serious subject matter. I promise to spare you the usual litany of the unmet needs in transplantation since we are all well aware of them.
I would like to begin with my own journey on the river of life from medical student to AST president, while paying tribute to mentors, colleagues and friends who have played and continue to play a critical role in my career and development. No man is an island, and one cannot accomplish a great deal without the support of a network of mentors and friends. When I look back at my journey in life I remember days that seemed to last forever, as the poet says, yet in hindsight the years have flown by like a bullet train. When I was growing up, I imagine I most resembled that little kid in the famous Italian movie, Cinema Paradiso. My family was in the movie business, so to pre-empt my cinematic aspirations, my parents decided to rescue me from a liberal arts education in an Italian high school and college and strongly encouraged me to pursue more scientific goals at the American University of Beirut. I half heartedly-complied. You see, I had aspired to be a movie director but in due course I got my MD degree.
I can say with certainty that my journey into the labyrinth of academic medicine started with an encounter with Dr. Christian Barnard, who was visiting our university soon after performing the first heart transplant in Cape Town in 1967. My meeting with him was my awakening to the exciting prospect of a career in organ transplantation. I came to the United States and started a wonderful fellowship at Emory University which instilled in me the love of clinical investigation. Those years at Emory have had a special place in my heart, and it has given me great pleasure in recent years to collaborate in clinical trials with Chris Larsen and his team at Emory.
As I was finishing my fellowship at Emory, I received a phone call from Dr. Floyd Rector, a true giant of nephrology, who was head of the Division at UCSF. He offered me a full-time transplant nephrology position, an offer that delighted me, having already visited San Francisco, and thus I embarked on a journey that has turned out to be more exciting than I could ever have imagined. This excitement was largely due to the excellent quality and the collegiality of faculty and staff I have been honored to work with in my time at UCSF. I would like to pay homage, however briefly, to the important people who have played vital roles in my transplant career. I had the good fortune to have worked with three individuals, who have successively headed the transplant program at UCSF in the past 30 years. They were both generous and visionary in their leadership of the program.
The first was Dr. Oscar Salvatierra, who was ahead of his time in understanding that a successful transplant team required equal partnership between surgeons and nephrologists. Under his leadership, UCSF became a model of a fully integrated program where surgeons and transplant physicians worked together in an environment of mutual respect. Oscar was followed by Nancy Ascher. She came to UCSF from the University of Minnesota having trained under Dr. Najarian, who had been the first Chief of Transplantation at UCSF in the early 60s. She established a strong liver transplant service in conjunction with the already successful kidney transplant service, and expanded and encouraged both clinical as well as basic research.
She was followed by John Roberts, the current president-elect of the ASTS, a great surgeon, (our inside joke is that he is the smartest internist on the transplant team). I owe both of them individually, and as a team, my success as a clinical investigator for the promulgation of a forward-looking culture of scientific endeavor that they brought with them and implemented at UCSF.
One of the great pleasures of my professional life has been my good luck to have had transplant nephrology colleagues who have actually become a part of my extended family. When I first came to UCSF, I joined Bill Amend, a great clinician and communicator. He was the elder statesman of the team. A few years later we found the perfect partner in Steve Tomlanovich, and we came to be known as the Three Amigos of Transplant Nephrology. Over the years we have bonded more and more and have become more like brothers than colleagues. With time our activities expanded, and as Bill Amend retired, our group has re-emerged as a quartet with Drs. Deborah Adey and Julie Yabu providing a perfect balance. We all know that a successful transplant service requires good cooperation and understanding between transplant physicians and transplant surgeons.
As our team grows and thrives, I am thankful to have as colleagues a group of transplant surgeons that are not only outstanding professionals with engaging personalities, but individuals with vision, intellectual curiosity and openness to experimentation. Peter Stock, head of the Kidney-Pancreas and Islet Program who has a passion for high mountain climbing, Chris Freise, Ryo Hirose (our in house wine expert), Sang Mo Kang, Sandy Feng and Andy Posselt. This outstanding group of surgeons are so much more than mere colleagues. I am honored to consider them my friends. With a raft full of my nephrology associates and transplant surgical colleagues, as well as the invaluable support of our coordinators, nurses, and staff, some of whom have been with us for 30 years, I’m sure we could face any challenging rapids in the river of our lives and on the UCSF Transplant Service.
Since the beginning, I have had the good fortune of meeting my wife, Eva, whose love and support I cherish every day. My journey would have been much less rewarding without her to share and rejoice in it. We have been blessed with 3 wonderful children, boys once, and now young men. Being technologically challenged, I do not know what I would have done without their constant help and support. My recipe for happiness has been balancing an exciting job with a loving and supporting family.
My journey eventually led me to become a member of the AST. I became involved in committees, chaired two of them, and finally was elected board member and president. With all the talent represented in the membership of the Society and on the magnificent Board, it is truly humbling to have had the honor to preside over this tremendously energetic Society. On the boat are members of our executive committee, Maryl Johnson, Jeff Crippin, and Barbara Murphy, as well as the skippers of the boat, the expert and constant guidance of our executive director Susan Nelson, the ebullient Tina Squillante, and the dependable Anna Shnayder. Not shown, but equally important, are the rest of the staff of association headquarters and, of course, the invaluable Pam Ballinger who makes the ATC click. We worked hard, but we also find time to have some fun. One of our Board meetings was held in the Napa Valley, and there can be no better way to relax than with a glass of wine at the end of a hard working day.
I ask myself sometimes: where is my journey taking me? Occasionally my wife asks me when will I retire. My usual answer is “when I stop having fun.”
Upon some reflection, I would like to pursue two challenges before I retire. The first one is to be part of a clinical investigation that establishes operational tolerance on a wide scale as a reality in transplantation. My colleagues often joke that I appear most excited when I am enrolling patients in a trial with novel agents. I am honored to have had the opportunity to participate in these trials. We cannot be complacent about our outcome results. Yes, our outcomes after transplantation are good but still fall short of providing our patients with safe, non-toxic immunosuppression that allows their transplanted grafts to function for the duration of their life. We need to continue to remain engaged with experimentation with novel drugs and regimens. The second challenge, which has been an interest of mine for the past twenty-five years, is to develop a therapy for recurrent focal glomerulosclerosis, a scourge that continues to be an important cause of graft loss and condemns a lot of patients, many of them young, to a life of dialysis. Collaborating with Dr. Virginia Savin in the U.S. and Dr. Ghiggieri and other investigators in Italy, we have made good progress but we do not have yet an effective therapy. In view of the exciting future ahead I feel that we are all very lucky to be part of the rewarding field of transplantation.
I will now turn to the state of our Society, basically our report card to you of what we aimed to accomplish this past year. I have been an active member of this Society for a number of years, but only as President have I come to fully realize the extent of the dedication and the hard work of our members as we advance the core missions of our Society in public policy and advocacy, education, and support for research. The commitment of the members of our Society is truly inspiring.
During the past year as AST President, in conjunction with our Board, I have overseen the progress of all the initiatives and activities that previous Presidents have put in motion. Additionally, there were specific areas that I was particularly interested in, shaped in part by my background and clinical interests, and I believe that the Society should seize and develop these opportunities further. While being a proud naturalized U.S. citizen, I am, as Ed Cole once noted, a citizen of the world. I still hold a European community passport and spent a good amount of my early life in the Middle East. I have been sensitive to the fact that while the AST is an American Society, its membership is international and, in fact, our members represent over 27 countries. I felt that we needed to have greater involvement of our international members in the activities of our Society and on our Committees so that we can extend our mission past North America to everywhere our members reside. Starting next year, we will be reserving a board position for an international member, so that we will have more direct representation of the needs and interests of members outside of North America. We have also extended our accreditation of the Transplant Nephrology Fellowship to centers outside of the United States and in 2007 the transplant nephrology training program at King Faisal Hospital in Saudi Arabia was the first center to receive accreditation. We have renewed our joint research grant with ESOT to foster exchange of trainees and young investigators between Europe and North America. We are also planning to expand our educational activities with two international symposia in 2009 on the emerging field of novel biologics in Europe and the Pacific Rim. The first symposium on novel biologics will take place in the United States on December 6-7, 2008 in Miami.
Clinical investigation and clinical trials have been a strong interest of mine for many years. The Society has taken several new initiatives in this area. We held our second clinical trial symposium immediately before the ATC in Toronto and we had a record of 140 attendees. The purpose of these symposia is to encourage young trainees and investigators to become interested in clinical research and provide them the tools to be successful clinical investigators. A major challenge in this field has been the approval process for novel drugs in transplantation, in particular the FDA’s insistence on defining very narrowly the regimens that can be used in control arms in phase I to III trials. This creates difficulties in designing trials that are meaningful, it discourages many centers from participating in them, the net affect being that trials are taking much longer to enroll patients and the type of patients that are being enrolled may not be representative of the patient population that we care for. I had the honor of joining Goran Klintmalm and Phil Halloran in an Editorial in the AJT to encourage the FDA to change their policies. My hope is that the FDA will adopt a policy that reflects the community standard of care in a timely manner.
This has been a year of many accomplishments for our Society in educational activities. We initiated a very successful one day symposium titled “Transplantation A Year in Review”, that was held twice in 2007 in Chicago and Dallas. This symposium is a digest of basic science, translational science and clinical research that have been presented at meetings during the year. This is the type of meeting we hope to hold in the future outside of North America for the benefit of our international membership. The AST Winter Meeting in March in Palm Springs had one of the best attendance records. The theme of the meeting was the increasing challenges associated with the high-risk donor and the high-risk recipient. Our annual meeting for fellows, which was held in September in Dallas, is invariably over subscribed with over 130 trainees attending the 2-day didactic symposium. This year we added a second meeting, the distinguished fellows research meeting, held in April in San Diego, dedicated to the presentation of their research project. Under the expert guidance of Don Hricik, our Director of Post Graduate Education, we have launched a series of podcasts dedicated to interviews with various leaders in the field of transplantation on issues ranging from science to public policy. We are also planning to launch a web service, “Ask the Expert”, to provide healthcare professionals with answers to questions relating to clinical transplantation and immunobiology.
Support of research remains one of our top priorities and this year we had the great opportunity to be able to provide grants for 17 trainees and faculty, which is the highest number that we have ever been able to offer. The importance that we place on education and research is reflected in the new mentoring award that we initiated this year and the first recipient was Mohamed Sayegh. The generous support of our partners in industry allows us to meet our educational and research goals.
One of the most active committees of the AST is the Public Policy Committee chaired by Dr. Briscoe and anchored in Washington DC by the resourceful Bill Applegate, and their list of accomplishments is impressive. The AST testified on Capitol Hill several times before the key health care committees and caucuses in the United States Congress. The Society worked closely with U.S. Senate and House of Representatives leaders to pass the Charlie W. Norwood Paired Donation Act. We convened an awards reception on Capitol Hill attended by more than a dozen Members of Congress to receive the Society’s leadership in transplantation award. In a rare move by Members of Congress, AST leaders and members of the Society’s Public Policy Committee were thanked publicly on the floor of the U.S. Senate and House of Representatives for their advocacy work in passing meaningful transplant donation legislation.
An important public policy issue that affects all our patients is the allocation system from deceased donor kidneys. On behalf of the AST, I have sent a letter to the KARS Committee of UNOS thanking them for their efforts but also encourage them to adhere to the following principles in the design of the new allocation system: a proper balance between utility and justice, without overt discrimination against any patient group whether based on age or disease category. The allocation system should be transparent and predictable for patients. We will remain fully engaged in the process to assure implementation of these principles.
A second public policy issue is the rising tide of regulation from various state and especially federal agencies. Regulation that improves patient care and safety is always welcome and embraced by our members. However, recent regulations in compliance and in patient care increase the burden of documentation at the expense of time dedicated to direct patient care, not to mention the increase in the cost. My friends, this is not a nuisance issue, it affects the resources that we have to allocate to fulfill these bureaucratic mandates. It is not surprising that the number of transplants, especially from living donors, has been flat. We have to be vigilant and courageous to contest those regulations that may imperil quality healthcare by forcing healthcare professionals into spending more time and effort on documentation.
Yes it has been a busy year, but fortunately we have accomplished a lot and all of us can be proud of the hard work that our members have done.
I would like to congratulate our colleagues from the ASTS board and in particular their leadership on the joint council, Goran Klintmalm, John Roberts, Mike Alecasses, Ben Cosimi and Robert Merion for their efforts. The 2 Societies, through their representatives on the joint council, meet twice a year to discuss issues relating to our joint projects, in particular ATC and AJT. This year as in past years, on occasion we have differed on certain issues. When we disagreed we did so without being disagreeable and I believe that at all times, we acknowledged our respective positions. I would like to thank Goran Klintmalm for sharing this philosophy and for extending to me a very cordial relationship throughout the year. Moving forward, I expect an era of increased collaboration between the 2 societies with the inspired leaderships of the incoming presidents of the AST, Barbara Murphy, and the ASTS, John Roberts. I believe this is what our membership would want us to do.
Finally, to the trainees and young faculty who will be the leaders of tomorrow, I would like to share Steve Job’s parting advice to the Stanford Graduate students in his 2005 commencement address: “STAY HUNGRY – STAY FOOLISH!” Reflecting upon it, I realize it has been the guiding philosophy of my life, and as much a blueprint for professional success as a motto for personal happiness. I wish this same success and happiness for all of you, and thank you again for the honor of this presidency.