In Their Own Words:
As an under-represented minority, I think sometimes I can relate to a patient who may look like me. Maybe be more inclined to go work in an under-represented environment, an environment that’s got socio-economic challenges, and maybe understand some of those issues. I think that the field of transplantation needs to reach out, to be more accepting of folks from Hispanic backgrounds, women, African Americans, and anybody who isn’t part of “the majority” to really provide service to those who need help.
Robert S.D. Higgins, MD, is the William Stewart Halsted Professor and Director of the Department of Surgery at The Johns Hopkins University School of Medicine. Following undergraduate studies at Dartmouth College, he went to Yale for his MD and later completed the MSHA degree at Virginia Commonwealth University. Dr. Higgins trained in general surgery at the University of Pittsburg and returned to Yale for his cardiothoracic fellowship, going on to Cambridge University where he served as senior registrar in transplantation at Papworth Hospital, the U.K.’s largest cardiothoracic surgical program and its main heart-lung transplant center. Prior to his appointment at Johns Hopkins, Dr. Higgins was Chairman of the Department of Surgery at The Ohio State University. He had previously chaired cardiothoracic services at Rush and Virginia Commonwealth Universities after directing cardiothoracic transplantation programs at Henry Ford Hospital and Children’s Hospital of Michigan in Detroit. Dr. Higgins has received many honors and has held numerous leadership positions, including presidencies of the Society of Black Academic Surgeons and the Association of Black Cardiovascular and Thoracic Surgeons, of which he is a founding member. He was elected President of the United Network for Organ Sharing for the two-year term 2008-2009, and from 2012 to 2014 he served as a Director of the American Board of Thoracic Surgeons. Dr. Higgins has authored more than 100 scientific articles and book chapters.
Interviewer: Bob, how and when did you become interested in transplantation surgery?
Dr. Higgins: Well I became interested in transplantation as a medical student in New Haven. And Dr. Wayne Fly was one of my professors, and I was just enamored with the idea that you could take an organ from another human being and replace it in a patient who was dying, waiting for an organ, and have that organ be accepted. And at that time, Wayne Fly who is a PhD in immunology, he was a really fascinating, great teacher. And he piqued my interest and I said, “Wow, if I could do something that would be extraordinary like that, transplantation might be a field that would be very deserving of my interest.”
Interviewer: And if you wish, your position and where you’re from.
Dr. Higgins: My name is Dr. Robert Higgins. I am the Director of the Comprehensive Transplant Center at the Ohio State University. I am also the Director of the Heart Transplantation Program and the Director of the Division of Cardiac Surgery.
Interviewer: Tell us a little bit about the history of cardiac transplantation in America.
Dr. Higgins: Well, the history of cardiac transplantation is very interesting and obviously well chronicled. I was introduced to Dr. Norman Shumway and Dr. Richard Lauer many years ago as a young cardiac surgeon. And I learned about the extraordinary work that they did in animal models to really perfect the technique of mid-atrial excision of the heart and re-implantation in a canine model. And they reported on that and obviously Dr. Christian Barnard kind of scooped them in terms of performing the first human heart transplant in the world.
But Dr. Shumway and the group at Stanford really have championed the cause and, I’m sure, have performed over thousands in transplants in humans. And they really helped to bring that program to fruition in the United States and across the world and perfected it with the advent of cyclosporin in 1981.
Interviewer: You rose in administrative position through your career to ultimately become President of UNOS. Tell us a little bit about your career and the non-intra-operative stuff.
Dr. Higgins: Well my career in transplantation really evolved from a very strong interest in making complicated systems work. And I knew as a young transplant surgeon that it wasn’t just about my technical expertise or having a donor or a needy recipient. It was about making a team of people work closely together. And I was aware of rules governing how transplantation was supposed to be conducted in medical centers across the country.
I got nominated to be part of a thoracic organ committee at UNOS and that was my first introduction to the regulatory environment of transplantation. And I learned an awful lot as a young person. And I became interested in understanding how the process of care, the regulatory oversight, and the clinical enterprise all interacted very effectively, particularly in highly effective programs.
I had the background of having trained at the University of Pittsburgh with great transplant leaders like Starzl and others, Henry Bahnson, Bob Hardesty, Bob Griffith, and I realized that it wasn’t just fantastic vision and great technical ability and a need in the patients. It was the ability to assemble a team of people to make it work, and then to understand how to make the process function effectively.
And that’s what piqued my interest in maintaining a role in Organ Procurement and Transplant Network, which mandates how the whole national transplant system works. And ultimately, I think folks saw that I was interested and passionate about it and I think I got nominated to a leadership role and became the President several years ago.
Interviewer: What were some of the highlights of your Presidency at UNOS?
Dr. Higgins: I was fortunate to be the President of UNOS from 2006 to 2009. I spent a year as the Chair of the Membership and Professional Standards Committee, which has very detailed responsibilities in terms of managing how programs work and ultimately making them better. And then the Chairperson sits as the head of the board of the Organ Procurement and Transplant Network and then recently I have been the Chair of the Foundation.
Each one of those experiences really was enriching and rewarding, but also challenging. It required time away from my family, who has always been a steadfast supporter. It required time away from my practice and my partners, who always were understanding but stressed by not having me there to do the work.
And it was really a battle, because I was a thoracic surgeon working in an area dominated by abdominal organ transplant professionals. And they kind of looked at me and said, “What does this heart guy know about belly transplantation?” And so I had to prove that I could stand in the room and understood the processes. My training in Pittsburgh, I think, was very valuable. And the fact that my wife was an outstanding abdominal organ transplant coordinator, so she has given me lots of insights about how the process works.
And so with that background, working to make the system work better, I think, was probably the biggest challenge. Building consensus among professionals who had very strong opinions about how things could work. Coming from their own disease-specific expertise, their own backgrounds in either kidney or liver or heart or lung or pediatrics or administration or from the lay community, each one of them brought valuable resources to the conversation about how to make the transplant system work better.
So I was really fortunate to be, I thought, a shepherd of the process, more so than anybody who determined or put my footprint on it. I think I really helped guide some of the conversations, and some of the more challenging ones included the discussion about kidney allocation, geographic variation in liver transplantation, disparities in transplantation. All of those things were very challenging conversations that required a facilitated conversation, and I felt like I was part of that conversation and I think we succeeded in some regard.
Interviewer: Off-camera we mentioned the diversity issue, the education issue, young surgeons. Do you want to comment about that?
Dr. Higgins: I think the field of transplantation is challenged by this question of diversity, as is healthcare in general. I think that the number of physicians that come from under-represented minority groups is about 3% to 4% in the United States. This is obviously a challenge. I think many patients, particularly those affected by kidney disease, hypertension, diabetes, heart disease, heart failure, all need our expertise.
And as an under-represented minority, I think sometimes I can relate to a patient who may look like me. Maybe be more inclined to go work in an under-represented environment, an environment that’s got socio-economic challenges, and maybe understand some of those issues. I think that the field of transplantation needs to reach out, to be more accepting of folks from Hispanic backgrounds, women, African Americans, and anybody who isn’t part of “the majority” to really provide service to those who need help.
It turns out that 37% of the patients on the wait list for kidneys, I think, are African Americans. And yet a relatively small percentage of them get kidneys. The donor pool is made up of a relatively small number of African Americans who still have deep-rooted concerns about donation. So as an African American surgeon and transplant professional, I believe that I have a perspective and maybe I can relate to folks who otherwise might not participate in the process. And I’m hopeful that I can provide that kind of insight and interest others to come into the field as a leader.
Interviewer: How are your younger folks doing in growing into surgery and transplantation? Could you comment on that?
Dr. Higgins: Well one of the advantages of working at a big, academic state institution is that we have a diverse student body. And one of the advantages of joining the faculty at Ohio State has been that I could interact with folks on a broader scale, across a broader landscape, and potentially influence folks to come into our field. I am really honored and privileged to be there.
But I have always had an opportunity to work in urban, academic environments, to be exposed to people of color, people of different socio-economic backgrounds, folks who kind of fall below the socioeconomic kind of curve, and relate to them effectively. I have been very fortunate. And so I think whatever opportunities I’ve had in places like Ohio State or Henry Ford Hospital in Detroit or the Medical College of Virginia in Richmond, each one of those environments is a tapestry, a rich combination of folks from the majority and the minority communities and I think that’s been a real blessing for me.
Interviewer: Talk about the ASTS and cardiac surgical colleagues.
Dr. Higgins: The ASTS has been a leader in the field, particularly in transplant surgery, for decades. And I feel a real interest in the Society; I believe that it has so much to offer. Creating an advocacy role for surgeons in the transplant field is really one of its primary roles, from my perspective.
I really think the ASTS could be the authoritative resource for transplantation in ways that many other organizations can’t speak to, so honored and privileged to have a role in that regard. I do think that it has been primarily focused on abdominal organ transplantation. As a cardiothoracic surgeon who is now leading a comprehensive transplant center, I believe that I can interface with my colleagues above the diaphragm and my colleagues below the diaphragm. And I think it’s been a wonderful relationship with the leadership at the ASTS.
I think the ASTS has an important role in transplantation, which has been under-developed, and certainly thoracic surgeons, heart and lung surgeons, have not taken advantage of the specialness, the uniqueness of the ASTS. I think that can change.
I do believe that cardiac surgeons and thoracic surgeons tend to see transplantation as one of many things that they do, but not the only thing that they do. And so in the course of a day, whether you are doing open-heart surgery or thoracic surgery, transplantation usually comes after the day’s schedule has been completed.
By comparison, I think my colleagues in the abdominal organ transplantation world are dedicated and passionate and focused on abdominal organ transplantation. That is their raison d’être and they tend to have fewer of the basic surgical procedures, although access procedures and other things take an important role.
So I think the challenge for the ASTS is to demonstrate that the scientific and the academic and the advocacy roles can really be very, very positive for chest surgeons. I think the issues with relation to lung transplantation, in terms of preservation, in terms of deceased donation after cardiac death, in terms of immunosuppression, in terms of ischemia-reperfusion are analogous to what kidney and liver transplanters see every day.
And so I think there is a real opportunity for thoracic organ transplanters to learn a lot from the abdominal organ transplant side, and vice versa. So I am hopeful that we can embrace the mission and vision of the ASTS and get thoracic surgeons to understand it and join in.
Interviewer: Tell us where you think cardiothoracic transplantation is going to be 10 to 15 years from now?
Dr. Higgins: I think the future of cardiothoracic transplantation is bright, but it’s going to be a challenge. I think the biggest challenge is the donor pool is limited in terms of the number of suitable hearts and lungs that can be transplanted effectively. And yet the demand among patients with end-stage heart disease and lung disease is extraordinary. Close to 20,000 people may be eligible for heart or lung transplantation, yet only about 2,000 to 3,000 heart and lung transplants are done each year.
And that’s primarily because the heart has to work, or the patient is going to die, at the time of implantation. Whereas primary graft dysfunction in a kidney can be tolerated and may be rescued with dialysis until the kidney kind of comes around. Our liver recipients do require early function and so the liver programs and the heart programs share a lot of commonalities in terms of early graft function.
But I think the biggest obstacle is going to be long-term that unless the donor situation, the supply of organs that could save heart and lung recipients, improves, it’s going to be relegated to one of many opportunities to help take care of patients. I think mechanical circulatory support, the total artificial heart, left ventricular assist devices are all going to have an impact on taking care of patients with end-stage ventricular dysfunction, waiting for transplantation.
We always think about xenotransplantation and as Dr. Shumway said, “Xenotransplantation is always going to be the future,” because it’s going to be many years before we cross the stumbling blocks, the biologic barriers that would allow it to be an important part of our armamentarium.
Interviewer: Tell us about any humorous moments in your career.
Dr. Higgins: I have some very fond memories that are quite humorous about my time at the University of Pittsburgh. When I was there, it was the busiest transplant center in the world. And on any given day, leaders like Dr. Tom Starzl, Dr. Henry Bahnson would be walking through the halls and would grab you by the collar and say, “Come on, we’re going to go see a patient.”
And I remember one time when we were pre-rounding early in the morning, before 5:30, 6:00 in the morning, and Dr. Starzl was walking through the unit. And I happened to be the only person in the ICU at the time, and he grabbed me by the lapel and said, “Come on, we’ll go see some patients.” And I was struck by how unassuming he was and how, I think, fairly he treated me. Yet he knew I was a junior member of the team and didn’t really have a clue about what was going on.
And I can remember him citing lab data from the previous day on patients. And before I could get to the list and confirm that the numbers were right, he was on to the next patient. And we went around the ICU, saw five or six patients and each one of them, I was looking for the numbers, and he remembered them. And he had a photographic memory, I think just phenomenal memory for details about what happened with the patient and why. And specific numbers like their SGOT and their PT and all of the other things that were going on.
I was so struck by that I said, “This is fantastic.” And yet as I was scratching my head, he was gone, and they were off to do another liver. And it gave me a real extraordinary exposure to transplantation. There are many other humorous stories that better judgment says I probably would just keep under my hat.
Dr. Higgins: But he was actually a very gracious professor and the whole Pittsburgh experience was a wonderful opportunity. I met my wife there, who has always been telling me that I need to kind of stay focused and check my ego at the door. So I think that’s probably the most valuable experience that I got from the University of Pittsburgh.
Interviewer: Talk a little bit about your personal life and transplantation.
Dr. Higgins: Well my personal journey in transplantation has only been enriched by my family and their commitments to support me as a young professional. As it turns out, I met my wife, she was an ICU nurse and she said she really wasn’t interested in marrying doctors because she didn’t want to follow their career.
And ironically, we have moved around the country, transplant fellowships in England, jobs in Detroit and Richmond, Chicago, and now Columbus. And at each one of those steps, I have been the beneficiary of unbelievable support from my family. I think probably the best part of it has been that my kids understand why I am not there.
Interviewer: Um, what do you want to add to this little story that I haven’t asked you?
Dr. Higgins: Well the personal journey through training and my personal life has really been enriching and extraordinary. As you know, after my son was born, we went to Cambridge, England, and did a transplant fellowship. And with a 2-year-old in tow, we had a wonderful experience there. I met people who are still life-long friends.
I think that each stage of my career, as I mentioned before, my kids have really been the fuel that keeps the engine going. Because sometimes if you’re not there for their birthdays or their ballgames, they become a bit detached.
I think probably the best story I can tell you is about my senior son, who had an opportunity to come observe a transplant and he got to carry the heart into the room and stand there and watch me do the transplant. After discussing that experience, I was pretty proud of myself, it went well. And he said, after I asked him at about 11:00 at night driving home, I asked him, what did you think? He said, “Dad, I think it was pretty cool.”
Dr. Higgins: In an understated way, I kind of got the feel that he appreciated all of those days that I wasn’t there. So fast-forward as I took him to his college interviews and he is a pretty good athlete, the coaches would ask him, “Well what do you want to do if you can’t play football or Lacrosse in college? What do you want to do with your career?” So, he said he wanted to be a doc, and I would not have expected that. So, I think that’s a pretty cool thing, and we’re fortunate to have that kind of opportunity.
Interviewer: About the future of heart transplantation or heart-and-lung, do you want to just broaden that a little bit, future transplantation?
Dr. Higgins: I think the future of transplantation is extraordinary. I get back to my original observation that we can take people who are at death’s doorstep, who have hours, maybe days to live, and give them a new lease on life. It takes an extraordinary gift; it takes a miracle for someone in the throes of a disaster, a loved one dies, and then they have, somehow, the wherewithal to donate an organ. And they give of themselves and of their family and of their loved one. And then that miracle turns into many miracles for those people who are waiting for transplants.
And whether it be heart, liver, lung, pancreas, kidneys, one donation can extend the lives of many, many people. And so with that miracle, transplantation has a very special place in the modern health care environment, in my opinion. And I believe that it’s a special place that will be maintained for many, many years. And as we get better at learning about how to identify donors and taking care of them up until the time of donation, and we spread the good word about donation and more people say “yes,” we will save more and more lives.
There are over 110,000 people waiting for organs, life-saving and life-enhancing organ transplants. I think that transplantation has a bright future, and I’m privileged to be part of it. I think it’s an extraordinary thing and I would encourage anyone, a young person, maybe my son, he may see the miracle that transplantation is and want to be a part of it, and I hope we can spread that word.
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