Jeffrey Crippin, MD 2007 Presidential Address

Fellow members of the American Society of Transplantation, attendees of the 2007 American Transplant Congress, ladies and gentlemen, and dear family and friends, it is with great pleasure that I stand before you today as President of the American Society of Transplantation. I welcome you to the 2007 ATC on behalf of our society and the American Society of Transplant Surgeons, the society with whom we have partnered to make this meeting the pre-eminent meeting in the field of solid organ transplantation.

Presidential addresses are often viewed as a necessary evil in any organization. A talk that occurs by tradition, though is often attended by few; listened to and digested politely by friends and colleagues, though frequently seen by many as an opportunity to get coffee, check the Blackberry, or take a break. However, the Presidential address does allow the person in the highest office of the society to reflect on the events of their term, whether it be on a personal, societal, or national level. Thus, I would ask you to consider my thoughts, as I reflect on the events that have occurred since I assumed the presidency from my good friend, Richard Fine, at the World Transplant Congress in Boston last July.

This year marks the 25th anniversary of the American Society of Transplantation, a professional society that has grown from the efforts of a small group of transplant nephrologists who formed the American Society of Transplant Physicians in 1982. Those humble beginnings have evolved into the society I have the pleasure of leading today. A society of over 2,700 members from every aspect of the field: physicians, surgeons, basic scientists, nurse coordinators, transplant administrators, and allied health professionals. ONE society and ONE voice for a multitude of professionals with ONE goal in mind: advancing the field of transplantation through the promotion of research, education, advocacy, and organ donation to improve patient care. Our society is ALL inclusive, just as is the field in which we work.

It is often stated that “There is no ‘I’ in team.” A simple and useful adage stressing the importance of the group effort over that of the individual. However, in spite of there being no “I” in team, closer inspection does reveal a “me.” The time worn adage continues to hold true. If one puts “me” first, one is left with either “meat” or “meta.” One could hardly run a transplant program or professional society with “meat,” while “meta” brings to mind terms such as “metastasis” or “meta-analysis” both representing uncomfortable terms in the treatment of patients and data analysis, respectively.

If the team is the key to success, what examples are there in the field of solid organ transplantation? I would propose our field is the model team. Consider the tireless efforts of those required to make a transplant occur and to maintain function of an allograft. Human nature often places one’s own efforts at the center of the effort, i.e., “the program could not go on without ‘me’.” However, placing “me” first undermines the efforts of valued colleagues. For example, a transplant surgeon is certainly needed to retrieve and suture in an allograft, but is that anymore important than the efforts of the physicians whose work to keep a patient alive may have meant countless hours at the bedside? Furthermore, could any transplant program run without the work and attentiveness of nurse coordinators, whose ears and eyes relay complaints and recent lab work that otherwise may have been missed? Would any physician in the room like to trade places with the secretarial help required to schedule the seemingly endless array of tests and office visits needed by our patients? What about those trained in organ procurement, pharmacy, and transplant administration? Finally, many of the treatments delivered at the bedside would not have occurred without the timely discoveries of basic scientists attempting to unravel the secrets of immunologic tolerance, drug development, or opportunistic infections, to name just a few. The “team,” ladies and gentlemen, is what makes our efforts blossom, no part being of anymore importance than another.

With the team in mind, all efforts must revolve around what is best for the patient. Each patient is surrounded by a solar system of support, ranging from our ancillary services to our most prominent physicians. Likewise, I would propose the field of solid organ transplantation is the center of its own solar system, with a number of supportive planets orbiting. If our field is to flourish, it is incumbent on us, as its participants, to provide for the future. Personally, I see membership in a professional society as a means of enhancing the future of the field.

Just as our field is based on the team concept, so is the work of the American Society of Transplantation. The AST serves the interests of all of its members. However, the work of the team often goes unrecognized. I would like to thank the members of our team for their efforts in the past year. My colleagues on the Executive Committee, Richard Fine, Flavio Vincente, and Maryl Johnson, have served as a sounding board and a source of inspiration during our many discussions. The legendary basketball coach at UCLA, John Wooden, once said, “Surround yourself with people who will argue with you.” What better way to describe our Board of Directors. They have often raised questions I frequently failed to recognize, once again leading to discussion. Finally, our 28 committees and communities of practice have invested hours of work to make our society what it is today, the leading society in the field of solid organ transplantation.

No society can operate on the work of the leadership alone. The AST is blessed to have Association Headquarters as its management company. They are the unsung heroes of our society, providing the time and documentation needed to keep timely records of our discussions and plans. Led by Susan Nelson, executive vice president of the AST, their efforts and patience are sincerely appreciated. Please stop by our booth in the entry way and wish them well. In addition to Susan, I would like to express my sincere gratitude to Anna Shnayder and Tina Squillante, two other members of the AH staff who have made my job infinitely easier with their ongoing help and advice. Finally, Pam Ballinger, the person who makes the ATC happen, has been a valued colleague and friend. I offer my sincere appreciation for all Association Headquarters does to make our society what it is.

My year as President of your society has been marked by crisis. Those of you in attendance at the World Transplant Congress, as well as this American Transplant Congress, were witness to demonstrations by members of the Chinese political group, Falon Gong, a group protesting the alleged use of organs from executed prisoners. These allegations reflect the continued evolution of our field. ANYTHING of value, whether money or the saving of a human life, often leads to efforts to procure the object of value by pursuing the path of least resistance, regardless of the ethics or morality of the means. The use of donor organs from executed prisoners is a deplorable practice. As a society and as a field, we should do whatever we can to prevent such atrocities. However, the acts of a few should not lead to the damnation of those centers upholding the ethical standards championed by our society.

Our field is the definition of “global.” The transplantation of solid organs occurs all over the world. Likewise, our patients now go all over the world in the pursuit of life saving organs, only to return home to the local center, expecting the quality care extended to and expected by our patients transplanted locally. Many have suggested these patients should be refused care, due to their decision to pursue transplantation elsewhere. However, isn’t our mission as a transplant team fueled by the charge to deliver quality patient care? Is this care going to be delivered by someone else in your community? Perhaps a primary care physician, with little or no knowledge of the use of immunosuppression and its effect on the allograft, much less its other systemic effects? I think not. As the transplant team, we DO care for those presenting under unusual circumstances: travelers, patients without records, patients without understanding or compliance. This is what we do. We must care for the sick and carefully assess the circumstances underlying the medical problems faced by each of our patients, avoiding judgment and maintaining objectivity.

This Spring, the Charlie W. Norwood Living Organ Donation Act was introduced in the House of Representatives. If signed into law, the issue of paired kidney donation as a “valuable consideration” will be clarified and eliminated.

The other crisis we, as a professional society, have faced, is running our society in an era of decreasing funds. This problem is no different than what your transplant team, lab, organ procurement organization, or even household faces on a regular basis. Historically, the bulk of funding for the AST has come from the generosity of pharmaceutical companies. These funds have allowed us to stay at the forefront of our field through education, research, and advocacy, all in the name of improving patient care. As this source of revenue decreases, our society will face important questions. Either programs and staff will have to be cut or other sources of revenue discovered. I would like you to consider another option: collaboration among professional societies and even the creation of a “super” society, a professional society addressing the needs of all members of the transplant team. Some have argued such a society will lead to a loss of identity of specific groups within the field. However, doesn’t the concept of a single society emphasize the day to day efforts of transplant teams everywhere? Economically, in this era of declining funding, it appears we have little choice if we are to survive and continue to thrive as a professional society.

As we look to the future of the field of solid organ transplantation, what better place for the exchange of ideas than the American Transplant Congress. The latest research and the exchange of ideas, befitting a field that continues to evolve. But what of the future? Please allow me to give you my personal opinion on where our field is going.

Issues regarding long term allograft survival will always dominate predictions of the future. However, I am going to concentrate on social and public policy issues affecting our field. Many of you are aware of my longstanding involvement with public policy issues affecting the field of solid organ transplantation. Our Director of Government Affairs, Mr. Bill Applegate, has taught me the details of the proverbial “give and take” on Capitol Hill. Effective lobbying is not a result of a one day fly in by thought leaders in the field. Messages are delivered and policy is driven by a daily presence in the offices of our Congressional representatives and those appointed by the President. Thus, I think much of our present and future success will be our ongoing interaction with our government on both a federal and state level. How we present our case to our representatives may be the difference between long term success and failure.

Ladies and gentlemen, we cannot transplant organs without patients, thus, access to transplantation should be a key goal in the strategic plan of any transplant professional society. Equal access to solid organ transplantation, in spite of what you may think, is not guaranteed in the United States of America. You may think this is related to a lack of adequate insurance or co-morbid conditions that make a transplant too risky. In fact, lack of access is often related to a lack of a timely referral. End stage organ disease with adequate insurance coverage, yet a patient is not seen at a transplant center because a physician either does not think transplantation is an option, there is a contraindication, or they just don’t know. As much as you in attendance may find this difficult to believe in the face of your involvement with the field, this is the reality in the offices of many physicians. How can this be corrected? Ongoing educational programs, starting in medical and nursing school and extending throughout residency programs, as well as updates provided at the meetings of ALL specialties and sub-specialties may decrease the frequency of such decisions. An increase in patient and public awareness will empower patients to ask their physician about transplantation, even if it has not been considered.

No patients, no transplants. Likewise, no organs, no transplants. Organ donation and organ availability remain a limiting factor in providing transplants to the over 90,000 people currently on the waiting list. Well meaning efforts at increasing organ donation did little to increase the number of available organs for years. However, under the direction of former Secretary of Health, Tommy Thompson, the federal government’s Organ Donation Collaborative led to a remarkable increase in the number of donated organs. Though criticized by some regarding cost, one cannot deny the success this project has attained and maintained since its inception. But can we do better? I think we can. A recent proposal from the state of South Carolina offered prisoners a shortened sentence of 180 days if they agreed to be an organ donor. Thus, an inmate would be rewarded with a decreased sentence of six months if they donated a kidney. Is this the answer? I think not. This smells of coercion of a captive group, hardly the message we as a society wish to send. But what of recognition of live or deceased organ donors? Is this such an abominable thing, if it involves a benefit, such as lifetime insurance coverage or a small cash reward? Furthermore, will it significantly increase rates of organ donation? No one knows because such a project has never been tried. In no way am I advocating the sale of organs, the concept of which I find reprehensible. However, a donation “benefit” to the family of a deceased donor or to a live donor strikes me as no different from the benefit given the family of a soldier struck down on the field of battle. The time has come for a pilot study to carefully examine the potential success or failure of such a project. Let us not assume this will or will not work. Let the data provide us with the answer. Finally, we know our pediatric transplant recipients have a marked decrease in allograft survival if they lose their insurance coverage. The time has come for legislation allowing insurance coverage for the lifetime of the allograft for our pediatric recipients, a project currently being pursued by our Public Policy Committee.

I would be remiss if I did not mention others who have profoundly influenced my career and my day to day professional life. Drs. Norton Greenberger and James Reed, at the Kansas University Medical Center, for starting the fire of passion for gastroenterology and liver disease; at the Mayo Clinic, Dr. Russell Weisner for his mentorship in my early days of training in the field of transplantation and Dr. Keith Lindor for his help in guiding my early efforts at research; at Baylor University Medical Center in Dallas, Dr. Dan Polter for giving me my first job and Dr. Goran Klintmalm for teaching me to think “outside the box.” I would also like to thank Dr. Arthur Matas, the President of the American Society of Transplant Surgeons. Arthur, we did not agree on everything, but you will always have my respect and gratitude for the interactions we have had the past year. There is no way I can ever repay all of these people for the guiding light they have provided. Furthermore, for all of the friends and patients I have within the field of transplantation that have touched my life, I thank you for your thoughts and encouragement.

The time and effort necessary to be the President of the AST would not have been possible without the assistance of my colleagues and co-workers at the Washington University School of Medicine and Barnes Jewish Hospital. My physician colleagues, Kevin Korenblat and Mauricio Lisker-Melman, have covered for me countless times when society business required my presence at an out of town meeting. My division chief, Nick Davidson, only knows me by a voice on a cell phone. My surgical colleagues, Will Chapman, Jeff Lowell, Surendra Shenoy, and Niraj Desai, have tolerated correspondence via e-mail, rather than face to face contact. Our nurse coordinators often think the medical director of the liver transplant program exists in name only. My administrative assistant, Sharon Zerjav, has been amazingly efficient at keeping my schedule organized, even in the presence of meetings and calls that occurred or were cancelled without warning. To all of them, I offer a sincere thank you, particularly as I look forward to being on call 26 out of the next 52 weeks.

My “team” certainly does not end at the hospital. In fact, my team BEGINS at home. All of you are involved in health care, in some way, shape or form. You are all aware of the unpredictability associated with day to day patient care. Add to this the unpredictability of the presidential responsibilities of a professional transplant society. Without the support of those closest to you, the ability to maintain a sense of sanity becomes impossible. Tolerance, patience, and compromise have been the theme in the Crippin family and household since last July, when I assumed the Presidency. Throughout my life, my parents, Christine and Kent Crippin, have provided support and encouragement. I am honored by their presence here today. Sarah and Katie Crippin, our 15 and 13 year old daughters have often asked, “Are you going out of town AGAIN?” in the last year. As I have watched them grow into poised young women, clearly taking after their mother, I am in awe of their accomplishments and their resolve. Finally, I can only hope that you have been or will be blessed with a life partner as wonderful as the one I have. In the summer of 1981, I was introduced to Nancy Stefkovich, my wife of just over 24 years. We have weathered the ups and downs seen in any relationship. Without Nancy’s tolerance, patience, and compromise, I cannot do what I do. Nancy, your dedication to our marriage and our family, are an ongoing source of inspiration for me and I am honored to have you as my wife and soul mate.

Finally, none of this would have been possible without my faith and trust in God and my savior, Jesus Christ. I would like to share with you a scripture reading, an image, and one of my favorite hymns. In the Gospel of Luke, the angel Gabriel tells the virgin Mary, “…for with God nothing will be impossible.” I see this as true for our field and our society. ALL THINGS ARE POSSIBLE. But none of it happens without faith AND hard work. One of my favorite images is that of Christ washing the feet of his disciples, prior to the Last Supper. This image was further emphasized to me at my Jesuit high school, where we were encouraged to be “a man for others.” This idea of serving others is key to my life and hopefully yours, regardless of your religious belief. In fact, I can think of no better theme for our field. As you leave today, remember the words from one of my favorite hymns, “The Servant Song” by Richard Gillard:

Won’t you let me be your servant
Let me be as Christ to you
Pray that I may have the grace
To let you be my servant, too;

I will weep when you are weeping
When you laugh I'll laugh with you
I will share your joy and sorrow
Till we've seen this journey through.

I humbly thank you for allowing me to serve you for the past year. God bless you all.

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