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Dr. Tilney

In their own words:

I got involved a little late with the American Society of Transplant Surgeons. I'm not sure why, but those of us in Boston thought it was a middle western thing and didn't pay much attention to it. And I suppose that mindset, incorrect as it was, lasted probably five or six years. But then we used to go to the Drake Hotel in Chicago, of course, where it was a small, intimate, extremely interesting, occasionally cantankerous and vituperative meeting, and it was wonderful.

Biography:

Nicholas L. Tilney, MD, headed the Transplant Service at the Peter Bent Brigham Hospital in Boston and was Director of the Surgical Research Laboratory, Harvard Medical School.  He attended Harvard College, obtained his medical degree at Cornell University Medical College, and received the bulk of his surgical training at the Brigham under its Surgeon-in-Chief, Francis D. Moore. He joined the faculty there in 1973 as a general and vascular surgeon. Dr. Tilney published over 550 scientific papers and chapters and edited two textbooks, in addition to being co-founder and co-editor of a review journal, Transplantation Reviews. His two books include Transplant – from Myth to Reality and A Perfectly Striking Departure: Surgeons and Surgery at the Peter Bent Brigham Hospital, 1912-1980. On several editorial boards of professional journals, he was President of the New England Organ Bank, the American Society of Transplant Surgeons, and The Transplantation Society. He accrued many honors, including The  Roche Pioneer Award from the American Society of Transplant Surgeons and The Roche Distinguished Achievement Award from the American Society of Transplant Physicians. Dr. Tilney passed away on March 13, 2013.

Transcript:

Interviewer: Nick, how and when did you become interested in transplantation?

Dr. Tilney: I became interested in transplantation because I came to the Brigham as a young house officer in 1964 and this was only a decade after the first identical twin. It was only two years after the introduction of azathioprine. It was only about a year after the introduction of steroids. So it was very early days. I thought I'd entered a lunatic asylum, I have to say. People were dying; it was like an abattoir. About more than half were dying within a few weeks or months after their transplant. We didn't do that many transplants, of course. Most of them came from deceased donors. There were no brain dead laws, of course; we actually sat around their bedside until their heart stopped, and then rushed them to the OR and took out their kidney and then put it in. You can imagine the incidence of non-function was very big.

The other obvious thing was that there was no sort of back up. I mean the only dialysis people had in those days was to do with acute renal failure and there wasn't any thought about chronic dialysis. A few people got dialysis to tide them over and they had to pay out of pocket for it. It was one of my first suggestions in my mind that maybe somebody besides the patient should pay for health care. And the attrition rate was really horrible.

I got caught up in the whole thing; the occasional successes were so successful that it was like a miracle and so I really got caught up in it that way.

Interviewer: Tell us a little bit about your actual entry into the field of clinical transplantation and perhaps the first transplant you did or scrubbed on, and the year and place and so forth.

Dr. Tilney: My first introduction to transplantation again was when I got there as a young junior resident in 1964 and I got put on that rotation. It was part of another rotation but I got involved with Joe Murray and got involved with Franny Moore's enthusiasm behind this whole thing. And I thought it was pretty interesting stuff. I thought the science, rudimentary as it was, was interesting. I thought the clinical part, when it worked, was extremely interesting. The operations, the few transplants we did, Dr. Murray had really defined all this in cadavers in the morgue before he started. I think the French really started the lower abdominal incision but he took it up rather quickly. Big incisions—vascular anastomoses in those days were really difficult because we had terrible needles. The sutures were threaded on in big holes, a lot of bleeding; it took a long time. Putting the ureter into the bladder was a real to-do. Nothing was very easy in this; it took hours and hours to get these things in. One time, we had the artery and vein anastomosis finished. The patient woke up, gave a cough, the kidney went shooting across the room, landed on the floor with a splat, and Dr. Murray, ever unflappable, said, “Oh, that's too bad.” So we, uh, wiped it off with an alcohol sponge and put it back in again and it did okay, I think.

Interviewer: Let's go to the middle part of your clinical career, sometime in the nineties perhaps. Describe your typical day and what the clinical day was like for you, the trainees, the students, and so on.

Dr. Tilney: Let me back up to the seventies for a minute.

Interviewer: Okay, sure.

Dr. Tilney: The mortality rate was still hideous; more than half of them died. And there weren't any fellows, of course; in those days, it was just residents and one attending, who did everything. We did everything to do with renal failure, colons and gallbladders and peptic ulcer disease and all the rest of it. But one of the things we did manage to do was to lower the mortality rate rather significantly by several things. Ultrasound had just come in, so we knew there were abscesses there. We reduced the amount of immunosuppression; they were still on azathioprine and steroids, but we used to think you could just give pounds of this stuff, kilograms of this stuff, and it would help. It didn't; it killed 'em. But we did manage to lower the mortality rate rather substantially in the 1970s despite trying all sorts of adjunctive immunosuppressive measures, none of which worked.

Now, by the 1990s, it had become rather much more…well, stylized isn't quite the right word, but much more regimented. The results were really getting very good. Cyclosporine had come in a decade before.

The results had gone up by about 20 to 30 percent. There was really hope out there; people were surviving not only kidneys, but all sorts of other organs now. So transplantation had really come into its own. It was not a proper rotation in our small hospital. We didn't have fellows, but we did have residents, and the residents loved the rotation because they did it all. I mean, we got quite good at this by that time, and they did these nice operations and they took care of these extremely complicated but improving patients, and it was sort of a very optimistic time.

Interviewer: You trumped me on the most memorable event in the operating room already. The kidney flew…you're the second one to have that experience.

Dr. Tilney: Yeah, I’m sure.

Interviewer: Or told about it on camera. The issue of organ procurement and preservation has always been with us.

Dr. Tilney: Yeah.

Interviewer: Can you speak to that a little bit in terms of the evolution from the seventies through now and how you see that?

Dr. Tilney: Yeah. Organ procurement and preservation has always been a problem.

Although in the 1970s and probably into the 1980s, there seemed to be a surfeit of kidneys and people in this country would send extra kidneys abroad for reasons that I never quite understood, meaning that patients here would not get them. That all sort of died away, I think, and as the success of transplantation got better and better during the eighties and especially during the nineties, the eternal problem of supply and demand got more and more problematic. Much more demand than there was supply, and these two things have been diverging ever since. UNOS came in, it became more organized, it became more regulated. Now patients were on a proper list, a national list. If an organ came up, the organ would be put on a national list and there could be much more sharing. I mean in the old days, in the beginning of it all, you know we are the New England Organ Bank, and the person that went out to harvest the kidneys, the idea was that he'd keep both of them or then as people got annoyed, keep one of them, and then as people got more annoyed, they'd go on the national list. But that evolution was quite long. Supply and demand is still not hardly solved. I mean we do 20,000 organs a year, whatever it is, and there're a couple hundred thousand that need them.

Interviewer: Right.

Dr. Tilney: And there's no rationale. There's no resolution.

Interviewer: Tell us a little bit about your earliest interactions with the American Society of Transplant Surgeons.

Dr. Tilney: I got involved a little late with the American Society of Transplant Surgeons. I'm not sure why, but those of us in Boston thought it was a middle western thing and didn't pay much attention to it. And I suppose that mindset, incorrect as it was, lasted probably five or six years. But then we used to go to the Drake Hotel in Chicago, of course, where it was a small, intimate, extremely interesting, occasionally cantankerous and vituperative meeting, and it was wonderful. The people in transplant all knew each other and we all liked each other and we all argued with each other, and so within a few years, the Society was something that all the members really appreciated and looked forward to its meetings. It was a great thing.

Interviewer: Let's go from that to your own evolution in the Society up to your presidency.

Dr. Tilney: I think it all started with a complaint on my part. I was always interested in the basic science of this stuff. I spent several years in England trying to learn this. I remember going to some of the Drake meetings and thinking it was too clinical. All this wonderful science was going on and nobody was paying any attention to it, so I complained.

I complained to the program committee, and so they put me on the program committee. In usual fashion. And so there I was, stuck with this bloody program committee. I'm not sure it helped very much, but I think we got more basic science on that. And then from there, it seems to me I ended up as treasurer—and my father was a stock broker, but his four sons, none of us can add and subtract, so that was a bad thing. But we managed to survive all that. We didn't lose any money. And then I became pre-president, I think, after that. As I remember, during that period we had a lobbyist from Washington who used to go down there and support our efforts and efforts such as ours.

I spent an awful lot of time pulling his incredibly verbose statements off the fax machine. I went to Washington a few times and talked to some of these bureaucrats, which was not thoroughly satisfactory, but anyway, that's the way it evolved.

Interviewer: Another thing you brought to your presidency of the ASTS, if I recall, was a little bit of an international flavor.

Dr. Tilney: Well, having grown up in this field, I had a lot of, international friends and contacts, and having lived in England for several years, I had a lot of international contacts so I thought it was a nice idea to get these people involved. And so we just used to invite worthies from elsewhere to give us excellent talks.

Interviewer: You were in Boston at the time and at Harvard; were you involved at all with the brain death circumstance?

Dr. Tilney: No, that was before my time.

Interviewer: Okay. That was before your time?

Dr. Tilney: Well, I mean I was a resident, but I didn't know about it.

Interviewer: I'd like you to talk a little bit about the family life that you have lived. Talk a little bit about the personal aspects of your life and the intersection of transplantation with that.

Dr. Tilney: Yeah, the personal aspects of one's life as a transplant surgeon and lab rat really, were… I mean it's hard. It's a hard balance; all of us have that problem. We have four daughters. I remember as a resident thinking that I'm just not home enough to see them grow up. Mary worked in the lab; she was our lab supervisor for 30 years I think, and we had a long-time relationship in that lab. And then our youngest daughter, we traveled a lot with her, so we've had a very nice family life all these years. It's been great.

Interviewer: Nick, is there anything that you want to say? I think we were going to mention something about Dr. Russell.

Dr. Tilney: Yeah.

Interviewer: And his contributions, so maybe back up to the Boston clinical programs in the early days.

Dr. Tilney: Well, I could say a couple things about the Boston effort, which was there in the very beginning. The Brigham effort we all knew about. Paul Russell was a gigantic figure in American transplantation but also international transplantation. Their program at the Mass General was, has been, and is premier. Tony Monaco was at the Deaconess, another hospital just across the road, and again another giant. So there was a lot of activity in transplantation and its science in Boston. Now there was a lot of competition, but along with that there was a lot of collaboration, and we used to talk to each other, which is somewhat unusual.

Interviewer: Nick, is there anything you want to add that we haven't covered?

Dr. Tilney: Well, just to say that my relationship with the American Society of Transplant Surgeons, has been a long one. It wasn't one of the first, but it's been a very long one. I think it's a terribly important thing. We’re the surgeons that do all the work, and I have enjoyed it tremendously.

Interviewer: Where are we going to be in 10 or 15 years?

Dr. Tilney: Probably the supply and demand problem is going to be worse. We're going to be continuing to fight commercialism I think. The science is going to be fantastic. Cellular transplantation, stem cells, are going to be very interesting, composite grafts are going to be very interesting. We've been extraordinarily successful here. But like many successful programs in biology, there are only so many resources, and so I think we're going to have the same troubles we have now. But we're doing pretty well.

Interviewer: Okay. Chantay, anything?

Chantay Parks: I didn't hear him say I'm Nicholas Tilney from so and so.

Interviewer: So, please just say your name and your position.

Dr. Tilney: I'm Nicholas Tilney. I have worked for many years at first of all the Peter Bent Brigham and now the Brigham Women's Hospital. I'm at present the Francis D. Moore Distinguished Professor of Surgery, which means that they don't pay you.

Interviewer: Okay, that's good.

[END OF AUDIO]