Dr. Peters: I'm Tom Peters, the Historian for the American Society of Transplant Surgeons. And with us today is Dr. Richard Howard, emeritus professor of surgery at the University of Florida. Dick. Welcome.
Dr. Howard: Hello. How are you?
Dr. Peters: We're good. I did want to chat with you about your career in transplantation, and why don't we start at the beginning, your early education and interest in science and transplantation.
Dr. Howard: Well, I grew up in Minneapolis, Minnesota. My father was a physician, my uncle was a physician, my brother went to medical school. So I had a natural push to go to medical school. Although, early in my youth I wanted to be a train engineer because we lived near switching yards and the steam locomotives they had in those days were fascinating. But that quickly passed.
So after I graduated high school, I went to Yale University and then went to medical school at Yale. But between my sophomore and junior year as an undergraduate, I worked in a physiology lab at the University of Minnesota during the summer and there I assisted a surgical fellow in cardiac surgery, operating on dogs. That's how I really got interested in being a surgeon. And he let me do a lot of the operating and I wanted to be a cardiac surgeon because he was going to be a cardiac surgeon.
So that's what I had planned to do. And then between two years while I was in medical school, I worked again in a laboratory at the University of Minnesota for Dr. Robert Good, who was one of the premier immunologists in the world at that time and started doing work in transplantation. But I really got interested in transplantation and it's like one of those events that everybody remembers although it occurred in a split second, and you never forget it.
I was in the library at the Yale Medical School studying pathology and it just occurred to me with no preparation, having never thought this: wouldn't it be interesting to see if you could transplant kidneys from one person to another? I have no idea where that thought came from, because I hadn't thought about it before. But it just arrived. And so I stopped what I was doing and looked in the medical index, which then was not online but was a series of multiple books you had to go through, and just to see what was done. And I was very disappointed to find somebody had actually thought of that idea before me, but that's how I got interested in transplantation.
So I started doing some work with one of the plastic surgeons at Yale because they were the ones who transplanted skin, and I did some preliminary but not very successful experiments in transplanting skin in rats with him. And then I decided to go into transplantation.
Dr. Peters: So from Yale back to Minneapolis to a surgical residency.
Dr. Howard: Well there was a diversion, because at that time during the Vietnam War everyone had to go into the army, every physician. So when I interned, I applied for the Berry Plan which would allow you to finish your residency and then go in as a fully trained surgeon. Well, I didn't get that so I was prepared to go into the army as an ordinary physician. I had applied to go to NIH but didn't get accepted there, but within a few months somebody had dropped out, and so a friend I knew, who was in this laboratory and was also interested in immunology, called me to see if I would be interested in coming.
So I spent two years in the Public Health Service at the National Institutes of Health, and I had never intended to go back to Minnesota. But while I was at the National Institutes of Health, Dr. Najarian accepted the chair in surgery at the University of Minnesota, so that's why I went back to the University of Minnesota for the residency and fellowship in transplantation.
Dr. Peters: Your training at Minnesota was more than just a surgical residency.
Dr. Howard: Right. In Minnesota, the program was started under first Dr. Owen W. Wangensteen, who was one of the giants of American surgery, and he wanted to train surgical scientists. So he had every one of his residents enrolled in a PhD program as well. And it meant that in addition to being educated in surgery, everyone spent two years in the laboratory, attended graduate school, and came out with a PhD in surgery or some other field. But it meant that you took two additional years, so now we had two additional years in the military or uniformed health service, a long residency, two additional years in the lab, an additional year of transplant fellowship (that was only one year at that time).
So we used to kid each other that we had a cradle-to-grave residency program, or as soon as we finished our residency we went right on Medicare. And my wife frequently said, “Tell me, does anybody ever just go out and get a job when they finish?” because she thought I'd never get done. While my wife Rebecca and I were going through this long residency and fellowship program, we did find time to have a couple of children.
We had two boys, David and Jonathan, and my wife initially started working for the Minneapolis school system, writing federal grants for the school system. Eventually, she stopped doing that and enrolled in a PhD program in education, which she subsequently achieved.
I had gone through the residency program, the fellowship program with David Sutherland, and we both then joined the faculty at the University of Minnesota as transplant surgeons. It became clear that there wasn't room for both of us and that he was doing work more in keeping with Dr. Najarian’s goals. So I started looking around for another job and three years later I moved to the University of Florida.
Dr. Peters: What were those early days like at UF?
Dr. Howard: Well, at the early days, the structure was similar to the University of Minnesota; that's one of the things that attracted me to the University of Florida. It was a relatively new medical school; it had only been formed in 1958, and it was small. The surgery department was small. When I joined it, there were only about six faculty members in the entire surgery department and Dr. William Pfaff, my predecessor, was doing transplants. He started the transplant program at the University of Florida, but he also was doing general surgery, and that was one of Dr. Najarian’s goals with surgery. He kept saying that we were general surgeons who did transplants, not transplant surgeons, because he didn't want to be button holed into a narrow field. Dr. Najarian liked doing vascular surgery, liked doing general surgery, which he did. So I could continue to do that at the University of Florida.
When I came there, there were two things that I sought to change. One, Dr. Pfaff at that time was doing about 40 to 50 transplants a year and I thought we could increase the number of transplants. The other thing, he was a great teacher, asked great questions, but his rounds which we made twice a week, formal rounds with all the residents and nephrologists, lasted generally from two in the afternoon till eight in the evening.
Dr. Peters: Goodness.
Dr. Howard: I could never deal with that. So we did then over the few years increase the number of transplants by getting a little more—aggressive may not be the right word, but broadening the acceptance criteria of candidates. And we did shorten the rounds from six hours to about two hours. He was a great colleague to have, very supportive.
The other thing he did at that time was a cooperative effort with the urologists when he started doing transplants. So he would sew in the kidney and a urologist would come and sew in the ureter. Well, at Minnesota the transplant surgeons did everything, so I started sewing in the ureter when the vascular anastomosis was done, and the urologists came and complained to Dr. Pfaff saying that they needed to do that to train residents. But Dr. Pfaff supported me and said, you know, he’s qualified; he can do it.
Well, this is an aside. So to show you motivations, the urologists continued to do the ureteral anastomosis for Dr. Pfaff because they needed it for their boards and their training until they found they weren't getting paid for it. Then all of a sudden the educational needs and their board needs weren't necessary, and they stopped doing them.
Well, I joined the ASTS shortly after it had been founded. I finished my fellowship in1976 and joined the next year. That was the first year I could be able to be a candidate for membership. And it was a small organization, collegial but in a certain degree competitive. And it was small enough that everybody knew everyone else. We met in the Drake Hotel, and every year we met in the same room, frequently on a weekend. One evening Fred Merkel, who had a house right on Lake Michigan north of Chicago, would have everyone over for dinner at his house. So it was a collegial organization, but it's—instead of competitive, a better word is challenging, because surgeons who were really the initial giants of transplantation challenged each other to do more transplants and to do them better. And virtually the only thing that was discussed and done during those early days were kidney transplants. Starzl of course was doing liver transplants; Najarian did a few but not very successfully in those early days.
It was an important organization for pushing the frontiers of transplantation, pushing the science, and overcoming the resistance of a lot of nephrologists. Because nephrologists, many of them, thought that transplantation shouldn't be done and there was a question of whether transplantation would even survive because it lacked the support of some nephrologists. They thought dialysis was better and was going to improve, and transplantation at that time, as you know, had a not good record; 40%, one or two year graft survival was the best you could hope for.
But these surgeons persisted and gradually, over the years, they expanded to do more transplants, they improved their technique, and they did trials with new immunosuppressive drugs as they came along.
Dr. Peters: So your early personal involvement with the ASTS as a young transplant surgeon—how did that go?
Dr. Howard: Well it went fine. I started of course as a very junior member amongst all these professors. So I was sitting generally in the back of the auditorium, not the front. But everyone was extremely supportive, and they knew that the field was still burgeoning and developing so they were looking to support everyone else in the field. And it was still small enough, so even though I was very junior and hadn't written much at that time, people still kind of knew who you were.
Dr. Peters: What was your first committee assignment?
Dr. Howard: My first committee assignment—oh, I know what it was. To be a member you had to have a transplant fellowship or similar training. But pediatric surgeons who were doing transplants had taken a pediatric fellowship and so they were ineligible for membership. So I wrote a letter complaining that they needed to expand the criteria for membership to people who are doing transplants but may have taken other fellowships. The same thing with the cardiac and lung transplants; they were done by people who hadn't taken transplant fellowships but had taken thoracic fellowships. So with that I was made chairman of the Membership Committee.
Dr. Peters: No good deed goes unpunished.
Dr. Howard: Right. So that was my first membership in a committee.
Dr. Peters: And then as you went on with the ASTS, tell a little bit about the evolution. You ultimately became president.
Dr. Howard: I didn’t serve on the Council. I was made treasurer and served for I think two or three years and then moved into the president-elect position and ultimately the presidency.
Dr. Peters: During that period though the organization actually was expanding, especially into professional education.
Dr. Howard: The American Society of Transplant Surgeons was continuing to grow from a small number in the beginning and every year the number of people applying for membership and the number of members grew. So the role of it increased, like education, and we had started a journal with the American Society of Transplant Physicians (now the American Society of Transplantation) and a combined joint meeting that became the American Transplant Congress that has attendees of about 5,000 or more now. And we started getting into more professional education of our members about the issues that were important for transplantation above and beyond just the science of transplantation and how to take care of patients that were extremely important in terms of regulation and reimbursement.
I know a couple years before I became president, they had set up a committee to try to hire a lobbyist in Washington. We decided that we needed someone to represent us because federal rule making, regulation, and legal activities were so important. So I was on that committee. As it turned out I was the only one who showed up when we went around interviewing several firms in Washington to make a choice and ultimately selected PPSV who we have currently. I was also involved in a committee to select a new executive director for the ASTS and again I was the only one who showed up.
So I met with several candidates and ultimately selected Katrina Crist, who had previously been the executive director of the ASTS, then resigned, took another position, and then came back.
Dr. Peters: You also have had a major interest related to infectious disease.
While I was at the NIH I worked in the Dental Institute. Now that's not a place where surgeons go, but it was a place there was a laboratory space available after I finished my internship. I was working in a laboratory that was devoted to periodontal disease and of course since that's bacterial and involved a lot of immunology, we did mostly immunology unrelated to dental work. But that's how we fit into their budget. I was doing some work in transplant tolerance, but one of the scientists there was working with viral diseases, a virus in mice that would induce immunologic—not suppression, but improve their immune status. And so I started working with him and ultimately worked with another virus that could increase immune capability. It was Venezuelan equine encephalitis, not a virus you like to deal with too much, but it affects horses much more than humans.
So that is how I got interested in infections. When I went to Minnesota all the transplant patients were housed on a ward, and of course one of the problems that transplantation had at that time—and it still does, but much more at that time—were post-transplant infections. Because we produce this experiment that hadn't existed before of patients purposely made immune incapable with immunosuppressive drugs; that's what we were trying to do to protect their kidney from rejection.
Well the downside of that is that many of them got infectious problems, and we would call our infectious disease colleagues, but at that time they were not all that helpful because they always wanted to wait until we had cultures and the sensitivities before treating. One of my mentors, Dick Simmons, got also interested in infectious disease and had the idea that maybe we need to treat them presumptively. And we would change antibiotics when we had the culture results, but by waiting for the culture and the sensitivities, and that was the dictum of infectious disease, many of them didn't do well.
So he came to me one evening after we made rounds, and he said, you know we really don't know anything about infectious disease; we need to write a book about it. Because his way of educating himself about problems was to force himself to write about it, because then he would have to learn about it. So that was the origin of our book on surgical infectious diseases.
Dr. Peters: How many editions did that book have?
Dr. Howard: Three.
It was initially published in 1982, and it went through two additional editions. And then interest waned, I don't know from the public who didn't buy it or from us who had had enough of it at that time.
Dr. Peters: So let's switch to what you were doing at the University of Florida.
Dr. Howard: When I came to the University of Florida I wanted to establish a database of all our transplant patients, because Minnesota had a database. I just wanted to make one at the University of Florida because it was a great source of papers at the University of Minnesota. And so I went to Dr. Pfaff and suggested that, and he said yeah that's fine except I know all the patients; you don't need to do that. At that time he had done over 500 transplants and in fact he did know mostly about the outcome, but I said nobody can remember the outcome of 500 patients. So I started. It was a tremendous task and I went through every chart of every patient that he had done—that was about 580 patients and many of them had multiple volumes—and extracted all the relevant data that we wanted to put into a database.
Dr. Peters: A paper chart?
Dr. Howard: Yes. These were all paper charts and thick paper charts. I was in the hospital every night and many weekends for a year; it took me that long to do it. And then we hired someone. He actually was a graduate student in anthropology but knew how to write databases. So he wrote our first database, so we would have something to put in, and then we all had it.
I and our transplant coordinator and a couple other people, but mostly just the two of us, had to enter all this data and that took a lot of time. Then we started doing it prospectively. So when we wrote papers, we never had to go back to the paper chart. At that time there wasn't an electronic database; the hospital said it had an electronic database, but generally if you asked for something you got about half of the number of patients. I think that was probably true of the most hospital databases at that time. But it was a great source of being able to assess not only how we had done and how we were doing, but also made it much easier to write papers.
Dr. Peters: One or two of the notable papers that you're most proud of, in terms of their impact.
Dr. Howard: Well, one was on what happens to transplant patients who reject their kidneys. Nobody was following that. Do they ever get a second transplant, do they stay on dialysis? That was one. Another was, what are the outcomes of second and third kidney transplants? And then infections in transplant patients also. Those were the general types of papers—and others too—that came out of this database.
Dr. Peters: One of the current interests you have is organ donation administration. Bring us up to date on what you're doing now with LifeQuest.
Dr. Howard: Well I'm currently the medical director of LifeQuest and oversee the medical management of the brain-dead donors. As you know, if someone is going to be a donor after cardiac death, we don't manage those at all because they're still alive. So we don't impact those, but once they're declared brain-dead—and not before—then we take over the medical management, frequently to treat their primary injury. Primary head injury, they've been dehydrated, they may as a result of their brain injury have diabetes insipidus and have either sodiums that are way too high or way too low, may need pressors.
So a lot of those things need adjustments and fixing before they can become donors, and you optimize the number of organs and the function of the organs, so that's what I'm doing currently. I'm not really involved in the executive functions of the organ procurement organization because we have an executive director who does that. I have been very interested in the pronouncement of brain death because I look at every brain death note on every one of our donors and every patient we are referred, even though they may not become a donor necessarily. So we have really launched a major effort to get every one of our hospitals to improve the quality of brain death notes.
And the other issue is we try to get our transplant centers to use more organs. I think one problem nationally is that many organs seem to go to waste. I think the latest figures I saw is somewhere around 20% of kidneys that are recovered for transplantation are not transplanted. There may be many reasons I'm not aware of, but I think some of the reasons are all the regulations and people looking over transplant centers’ shoulders. Transplant centers naturally are reluctant to transplant kidneys or other organs if they think they're too “risky” because, if it impacts their outcomes in a negative way, their transplant center possibly may cease to exist or they may lose insurance contracts.
With the current oversight I think many transplant centers are reluctant to either list patients who they think are “too risky” or transplant organs they think are “too risky,” and I put that in quotes because many transplant centers are transplanting those kidneys. I think it may reflect the outcomes of the transplant center, the risk taking ability of the transplant surgeons, because there are different criteria depending what surgeon happens to be on that day when the organ becomes available.
I did a study in our service area several years ago; I don't know if the data are still true. We have two transplant centers in our service area, and I looked at all the kidneys that were refused by both transplant centers and then transplanted elsewhere. First of all, all the kidneys that were refused by both transplant centers had a hundred percent initial function when transplanted elsewhere. So I made that available and raised some eyebrows. But it just shows that they may have had good reasons for turning those down, it may just be the patient issues; I don't know, I didn't look into that. But there are kidneys perhaps that are turned down that should be transferred.
Dr. Peters: Do you want to add anything more about Bill Pfaff?
Dr. Howard: Bill Pfaff was the transplant surgeon who hired me at the University of Florida and really one of my mentors. He was a great guy, just straight arrow, dead honest, and really very supportive. He initially took his internship at the University of Chicago and then went to NIH for a couple years and then took a general surgery program at Stanford. Well, he happened to room with two other residents who were thoracic surgery fellows, and so they were studying for their thoracic boards. At that time you didn't have to take a thoracic surgery fellowship to take thoracic surgery boards.
So he took the test as well and passed it even though he had never taken a thoracic surgery fellowship. Since it was a lifelong certificate at that time, he was also a board-certified thoracic surgeon although he never did many chest cases. When he came to the University of Florida right out of his residency program, he had never seen a transplant, never done one. So when the nephrologist wanted to start a transplant program, he and one of the nephrology fellows went up with H.M. Lee in Richmond to learn how to give immunosuppressive drugs, and then he came and just started doing them not having seen one before.
He had done a lot of vascular surgery. At Florida, when he came there in 1964, there were only four surgeons in the surgery department, so everybody did everything. There was no sub-specialization within surgery. So he did vascular surgery, he did general surgery, and he continued that, which is one of the things that was attractive about my coming there that we could not only do transplants but we could do general surgery. Because we didn't have any vascular surgeons at that time, we did all the vascular surgery, and because transplant patients on dialysis frequently had parathyroid disease, we did all the parathyroidectomies. We did all the endocrine surgery. And gradually as the department matured and subspecialists came in, we more and more concentrated on transplantation surgery.
And then I took over as division chief when he retired in 1995, and he unfortunately passed away a couple years ago.
Dr. Peters: You are a gardener.
Well my interest in gardening also comes from my father; he had a huge garden and worked there every weekend and tried to get me to do it. I mowed the lawn but I didn't have much interest in gardening at that time. Then after we moved to Florida, I did get interested in gardening, and it was different from Minnesota, which I was used to, because in Minnesota you did the planting at the end of May. Memorial Day was a time for planting. Well, if things weren't in the ground in Florida by February, you didn't get anything because it got too hot. I still have trouble trying to get myself to go out there and plant things in February because snow is on the frozen ground in Minnesota. But I like to grow roses and orchids.
Dr. Peters: Do you show your specimens?
Dr. Howard: I don't show them, but I do like to photograph roses. And I’m a member of the American Rose Society and they have photographic contests. I won a couple. So I like to do that and like to photograph also.
Dr. Peters: So the other famous surgeon who was I think president of the Rose Society was Robert Zollinger.
Dr. Howard: Right and that was the same year he was president of American College of Surgeons, he also liked to grow roses.