Dr. Merion: I’m Bob Merion. I am Professor Emeritus in the Department of Surgery at the University of Michigan and President and CEO of Arbor Research Collaborative for Health.
Dr. Sung: I’m Randy Sung. I’m a transplant surgeon at the University of Michigan and I’m here today with Bob Merion, who is Professor Emeritus at the University of Michigan, a former president of the ASTS, and the former principal of the Scientific Registry of Transplant Recipients and one of my big mentors who’ve helped me very much in my career.
Dr. Merion: Thanks Randy, very nice to be here.
Dr. Sung: The first thing I want to ask you is how you first got involved in transplant surgery. What started your interest in it?
Dr. Merion: I was not interested in transplantation growing up, and during my progress toward college and medical school, I actually was certain that I was going to be a surgeon and I was pretty certain I was going to be a heart surgeon. I was really intrigued by some of the early advances that were in the popular media about heart surgery in the 1960s.
When I got to my surgery internship in 1979, the last two months of my internship I was assigned to the transplant service, which at that time was just kidney transplant. Doctor Jeremiah Turcotte, who was my mentor, was the chairman of our department. He had actually done the first kidney transplant in the state of Michigan and was one of the attending surgeons. That service, which was called red two, was infamous in the surgery department. It was thought of as the least desirable rotation. It was thought of as the most difficult rotation for the interns and residents. The patients were ungodly sick and not infrequently died, even after kidney transplants. There were lots of emergency calls, and most people tried to avoid being on that service.
I was assigned to that service for reasons that are unknown to me, not only for one month but for the full two months at the conclusion of my internship. And I thought okay, I can steel myself to this and I can tolerate pretty much anything. And I had made it through most of my internship. And then I got onto the service and I thought, “Oh my God I love this!” It’s tough; it’s not easy. I like tough. It’s unknown from one day to the next; you didn’t know what you are going to get. As Forrest Gump said once, it was like a box of chocolates; you didn’t know whether you were going to be doing a transplant that day or whether you were not.
And then I was rewarded at the end of the internship by receiving my schedule for the second year, and my first month of my second year of my surgery residency was on the transplant service. So I had three months in a row on the transplant service. No one had ever had that happen to them before, and the nurses on that unit, who were amazing and who really sustained me when I was running ragged, at the end of that three-month stint made a little plaque for me that they called the DSA, the distinguished survival award, because I had survived three months on the transplant service. But by that time I had been smitten by transplantation. We didn’t know anything really about the immunology; the surgical procedure was pretty standardized but it was being done still uncommonly enough that it was a bit of an adventure each time. So it was a technical challenge, it was an intellectual challenge, it was a patient care challenge, and I knew after that that transplant was what I had to do.
Dr. Sung: You were hooked.
Dr. Merion: I was hooked.
Dr. Sung: And then how did your career evolve from there? I know you spent time with Sir Roy Calne and then fellowship at the University of Michigan.
Dr. Merion: Yes, so in our surgical program, as you were nearing the end of the third year of your residency, you would have your meeting with Doctor Turcotte to figure out what you were going to do during your laboratory time. And typically at Michigan you spent either one or two years in a research lab and then came back for the last two clinical years of your training.
So I still remember in an old building that no longer exists on the campus called the Clinical Faculty Office building, I had my meeting with Doctor Turcotte in his office, and he knew by then that I was very interested in transplantation. About five minutes into the conversation he basically stopped and said, “Well, we’ve talked about transplant a lot already Bob, so I know you are interested in transplant and here’s the thing.” This is now 1981. He said, “Liver transplantation is a mess right now; it’s being done in only a few places around the world; it’s mostly unsuccessful. People are still not even sure whether it is something that we should actually try to do, but I think it’s the next big thing. I think it’s what is going to take off.” And his advice to me was to pursue a research fellowship in a place that was one of the active liver transplant programs. Basically his advice was go to one of three places. Go to Pittsburgh with Tom Starzl or go to Hanover, West Germany (this was before German reunification) with Rudolf Pichlmayr, or go to Cambridge with Roy Calne.
And his advice, in sort of sotto voce, was, “You should go to Cambridge, because Pittsburgh is a great place; they are doing a lot more liver transplants than they are in Cambridge, but they have a million fellows, both U.S. and foreign fellows. You would be having to elbow people to get any access to the clinical program. They have great science and you would probably do some interesting experiments, but I want you go there and get some experience on the clinical side as well.”
So I went home and I talked to my wife Debbie, and I said, “Doctor Turcotte thinks that we should move to England for a couple of years.” And she said, “We’re not moving to England.” And I said, “Well, think about it.” And so she thought about it, and in her usual very methodical way, she looked into what the opportunities would be for her career. It turned out to her pleasant surprise that there were quite a few opportunities for her, which she then pursued, including, as part of her due diligence, ordering physical telephone books from the British telephone company to actually go through the yellow pages. This was before the internet was really possible. So she really got us all set up and she helped to figure out where we were going to live and all that.
Doctor Turcotte, in the meantime, picked up the phone and called Roy Calne. He called out to his secretary, Kathy Bilotta—I think you may have known Kathy back in the day—but Kathy was his secretary and assistant and really surrogate for probably 40 or 45 years. Kathy trundled in during my follow up meeting and said, “Doctor Turcotte, I have Doctor Calne on the phone.” Now of course in England you wouldn’t have called him Doctor Calne; he was either Professor Calne or Mr. Calne because he was a fellow of the Royal College of Surgeons. But anyway, he gets on the phone, and in probably three minutes I had my research in clinical fellowship set up, because they knew each other. As much of a small club as transplantation is today, it was even smaller 36 years ago. So that’s how I ended up going to Cambridge.
Dr. Sung: And what did you do in Cambridge as far as research, and what was that experience like?
Dr. Merion: I was set up initially with a couple different experimental programs. One was a pancreas transplant program that I pursued with Gabsi Brons, Su Metcalf was doing some early work with T cell activation, and then I also was working on some tolerance work. This was the early days of cyclosporine and we were working with some congeners of cyclosporine, particularly cyclosporine G and cyclosporine C at the time. And we were doing animal experiments, both kidney and liver transplants in both dogs, as well as some subhuman primates. We were evaluating whether those congeners would be better or worse in terms of immunosuppression and potentially advantageous in terms of toxicity.
So those experiments went on. Because we were doing porcine experiments, I had the job of doing the porcine mixed lymphocyte culture reactions. And pigs have very low peripheral white blood cell count, so it was actually difficult to get enough white cells from the pigs to actually do the MLCs. That was very challenging, and that was a big part of my job. Another part of my job as one of the research fellows was that we actually ran a polyclonal RIA to measure cyclosporine levels for the patients on the ward. It wasn’t a CLIA and CAP certified lab; it was just the fellows went and had to actually participate in running the assays. So that wasn’t part of my research, but that was part of my job.
Dr. Sung: And then once you got back, were you a big part of starting the liver transplant program at Michigan at that point?
Dr. Merion: I had a really fantastic and unique opportunity when I returned in 1984. Doctor Turcotte had gone to Pittsburgh for a brief stint to observe several liver transplants, but of course he had been a portal hypertension surgeon and a liver surgeon for most of his career. I think for many senior surgeons in those days, it didn’t really occur to them necessarily that they needed to do a fellowship to learn how to do this operation, and Doctor Turcotte was among those. But on the other hand, he recognized the tremendous experience I had had because I would work in the lab during the day and then if there was a donor that night I would go out on the donor, and then I would come back and I would participate in the recipient surgery. And then if I still had any wind left, I would go back and check on how my experiments were doing at the lab.
So as we were preparing for our clinical program, we would use the animal laboratory as a way to essentially train up on the technical parts of the operation, which in the pig you have a fair number of similarities to the human. So I was in the unusual circumstance of mentoring my professors of surgery and the chairman of my department when I was a senior resident, which was an unusual position to be in.
And when the time came for the first clinical case, that was even more daunting. As was sometimes the case in those days, the early days of liver transplantation once it went beyond the original pioneers, the operations were very long and very arduous. Our first liver transplant went 17 hours, and I was called in to stand on the opposite side of the table from Doctor Turcotte. He did the operation, and I provided commentary as we went along and did my best to try to insert what I thought were helpful observations without appearing to be telling him what to do. So that was a bit of a challenge. That went on for a while, and he did the first half dozen or so before he decided to have any of the other surgeons really actively being the primary surgeons for those cases.
Dr. Sung: And you stayed on at Michigan, obviously, and you became the director of the transplant program as well.
Dr. Merion: I did eventually, yes.
Dr. Sung: Going back to your earlier career, what was a typical day like for you as a surgeon and clinician? It must have been very different from what it is today.
Dr. Merion: In some ways it was different; in some ways it was the same. I would say the typical day if we were doing a transplant was we’d get a call that there was a donor somewhere, we would have elective cases in the OR or we would have patients to see in clinic, we would finish up our day by the time they would set the donor OR. We would go out at night, in a helicopter or a plane, we would do the donor surgery, we would bring the organs back, and then not infrequently—in those days there were only two or three of us—so we would often just do everything. We would go out, do the donor, come back, do the liver transplant, often follow the liver transplant with a kidney transplant in a different patient. Then there might have been more elective cases from the next day to do, and then maybe go to clinic and then collapse in a heap.
And there were times when we did two or three of those with very little sleep. Looking back, it was not a good arrangement, but we sort of did what we had to do. And then like most programs, we had a laboratory that we tried to maintain, and our clinical perfusionists for the transplant program that would go with us on the donor procurements, they also functioned as our lab techs. So they were one and the same. So we really spent a lot of time with a small tight-knit group of people, and that was sort of how we spent our days and nights.
Dr. Sung: Now, I think if you asked most people in transplantation, they would have the idea that you created the Scientific Registry of Transplant Recipients. So how did that come about, and how did you get involved in not only the scientific registry but just in high-level outcomes research?
Dr. Merion: Well that has certainly been a major source of pride for me throughout my career. It was good timing. So the Scientific Registry was part of the National Organ Transplant Act, and like the internet, it was created by then Tennessee senator Al Gore. He was one of the writers of the original National Organ Transplant Act, and they envisioned an operational arm, the Organ Procurement and Transplant Network, and a companion contract for the Scientific Registry.
The initial contracts were both given to one organization, which became the United Network for Organ Sharing or UNOS in Richmond, Virginia. And UNOS held both of those contracts for the first several rounds, and I think a lot of people, myself included, thought it was all one thing. And then along came a health economist by the name of Philip Held, who had worked with colleagues of mine at Michigan. He was at that time at the Urban Institute in Washington, DC, doing health policy research and had an interest in kidney transplant and dialysis. And he was working with Bob Wolfe, a biostatistician, and Fritz Port, a nephrologist and epidemiologist, and they worked together on the early United States Renal Data Systems. And Philip came eventually to Ann Arbor and approached me and said there is this scientific registry, this is something I think we could make a real contribution to. Would you be interested in participating?
And my knowledge base at that point was fairly limited, and I said, well that sounds really interesting. I had always been interested in the intersection of databases and medicine, and I said, sure. So we applied and we did not win. And five years later, he says it’s coming up again and I think we might be in a better position to win, and I said, I’m willing to give it a shot again. So I took a sabbatical leave from my position at the university and spent almost the entire time working on the application for the SRTR, the scientific registry. And lo and behold, we won, and for 10 years we got to have the privilege and the responsibility of managing the data that informed public policy development for organized transplantation in the United States.
And my role was to provide clinical insight to our team of analysts and biostatisticians and to provide reports to various UNOS committees, to inform the process of policy development. I’m very proud of the work that a very large team of probably 20-25 people did during that 10-year period. Almost every single organ system went through a major transformation in the way that deceased donor organs are allocated based on work that we were charged with and had the opportunity to work on.
And we developed some new principles, we developed some new methodologies. And one of the things that I’m most proud of is that we vastly expanded access to all of that data. Those data really belong to the transplant community; they are supplied by the transplant community to the Scientific Registry, and one of my strongest inclinations in putting together the application and one of the points we tried to make most strongly was that these data should be available for any bona fide scientist to be able to utilize and to mine those data.
And our philosophy was let the best science win. Let the peer-review process and the evaluation of the science that comes out of those data judge who gets the most publications, and it shouldn’t just be a small clique of people who have access. And that has persisted to this day. Hundreds if not thousands of papers that have contributed to advances in transplantation have come from that work. That’s one of the things I’m most proud of.
Dr. Sung: Now in addition to the work you’ve done for the Scientific Registry, you’ve also spent time helping other countries with their transplant registries. Can you talk a little bit about that?
Dr. Merion: Sure, those have been great opportunities; we have had interactions with the UK transplant service, with the Australia and New Zealand registry, some interactions with the Korean registries and also with the China liver transplant registry. All of those interactions have been most valuable, I think, in identifying areas where a practice within one country, or within one region, can’t necessarily be ferreted out, but if the practice varies between two regions and you have differential outcomes, then you can identify some potential impacts of practice on outcome. And that’s an area that has been of great interest for a long time.
There’s a lot more that could be done and should be done in that realm, but it’s challenging, because each country sets up its registry in its own way, and just getting the data in a form where it can be merged and those analyses can be done can be challenging. But we have I think done a good job of identifying some opportunities there.
Dr. Sung: I wonder if you could talk a little bit about your involvement with the ASTS. You’ve obviously been an active member for a long time and contributed greatly. Can you talk about what the ASTS has meant to your career, how it’s evolved? Reflect a little bit on your presidency?
Dr. Merion: The ASTS really is almost synonymous with my career. I don’t think without the ASTS I would have done half of the things that I had the opportunity to do. I recognized early on after I was smitten by transplant that having a professional group with a similar affiliation was really going to be key to being able to make any kind of contribution to the field. And so I sought out opportunities to serve the ASTS as early as I was able to become a member. And I still remember getting the letter saying that I had been admitted as a member of the American Society of Transplant Surgeons. It was not just 25 cents and two cereal box tops; it was a real application, and you had to have showed some bona fides in transplantation to get in.
So I was very proud of just becoming a member of the ASTS. I then made it clear to anyone who would listen to me that I was interested in serving on committees. One of the earliest committees I served on was the Scientific Studies Committee. I also had opportunities to serve on the Ethics Committee, and then as time went on and my involvement became more substantive and I proved myself, I guess, I eventually had the opportunity to run for a position on the Council, which I did win. Then later, I became Secretary and eventually became President-elect and President of the ASTS, absolutely the pinnacle of my professional career as far as I’m concerned.
The ASTS during that period of 20 years or whatever from my initial membership until I became president of the organization really went through an unbelievable transformation. It became a much more professional organization. It was founded on really strong principles of science and training; it has remained true to those principles and has expanded on them, but it has also expanded into other areas of public policy engagement. The Society made important contributions, for example, during the time that I was involved with the Scientific Registry in ensuring that people were paying attention not only to how much data can we collect, but are we collecting the right kinds of data and are we putting the right emphasis on any new data elements that were being asked for. That they should always have a purpose, there should be an end game for them. If we were going to collect more of something, we should be at least considering whether we could collect less of something else, because there is a real cost to these kinds of endeavors.
The other place where I think ASTS has made a real impact is to join the conversation about how we should be evaluating transplant program performance. ASTS has been a leader I think in that realm for many years and has had a very active and increasingly respected voice of reason and circumspection in figuring out how we can get good information to patients about what kind of activities and what kind of outcomes they can expect at a given transplant program.
I think that is a very important feature of ASTS that I think sets it apart from most other professional scientific and academic organizations: We really are what I would call a white hat kind of organization. In almost every discussion at committee meetings, at our Council meetings, and in public forums, what ASTS stands for are the patients and the donors. There are certainly some activities that are intended to help sustain and enhance the organization itself. But fundamentally the things that people I find have been most passionate about are things that are going to benefit patients. That has meant the world to me, to be involved with an organization that really cares about patients and is focused on patients.
Dr. Sung: What do you see the role of the ASTS evolving into in the future?
Dr. Merion: The ASTS will, in my opinion, continue to place its principles first, and in the future I would see it returning even more strongly to its roots, in terms of advancing the science of transplantation. We have reached somewhat of a crossroads in the practice of transplantation. We have a relatively shallow pipeline for immunosuppressive drugs to prevent and treat rejection for our patients. We have not really been able to crack the nut of the drastic imbalance between the number of donors and the numbers of potentially beneficial recipients, and I don’t think that the answer is going to be the next better drug or the next way to encourage more people to donate. I think those will be incremental, but I think ASTS should be and I think wants to be about the quantum advance. In my view, where ASTS should put its efforts is in the science that will lead us ultimately to bioengineered organs and to reduce the need or even eliminate the need ultimately for human organs for transplantation.
It may be that that will end up going down a xeno route using animal organs, engineered, or it may be totally bioengineered organs. There is certainly a lot of very exciting work going on right now.
We need to in the ASTS figure out what our moon shot is. That’s a little bit of a hackneyed phrase, but I think the ASTS would do well to take its substantial intellectual and tangible assets and think about what is the moon shot for 10 years from now, 20 years from now, that we want to really invest in. So that when people look back in 2030, 2040, 2050, they will look back and say the reason we have this and the reason that transplantation is now a routine practice that’s not donor limited is because the ASTS played this important role in making it happen.
Dr. Sung: Now you were also very instrumental in the development of the National Living Donor Assistance Center, which is a very important ASTS initiative. Can you talk a little bit about that?
Dr. Merion: The National Living Donor Assistance Center has for the last 10 years provided reimbursement of travel and other subsistence expenses for potential and actual living organ donors who otherwise might not have been able to afford that cost of getting to the transplant center in order to be evaluated. It’s been a source of great pride; we have a great team. The ASTS has been an important partner in that and really runs the front office operation for it. I became involved with it in collaboration with Doctor Akinlolu Ojo, who was then at the University of Michigan and has since moved to the University of Arizona.
And the idea was that there are invisible donors out there. And what I mean by invisible donors are people who would love to donate to a friend or a loved one or a family member, but they just can’t afford to fly to California, or to fly to Florida or to fly to New York to be evaluated. There are many people in this country who don’t have that luxury. There are people who have participated in the program who have never had a credit card, who live in a cash economy and live from paycheck to paycheck or pay envelope to pay envelope. We’ve been able to enable thousands of individuals to be evaluated and thousands of individuals to fulfill their dreams of becoming an organ donor and helping someone else through this program. It’s funded by the federal government. We are hopeful that over the next several years we will be able to interest third party payers and other sponsors to be able to fund the program.
Right now, it’s means tested, so it’s focused on the people who can least afford to be out of pocket, and people who cannot afford an airplane ticket also frequently cannot afford time off work. And as a result, there is another pool of invisible donors who would donate but they can’t, because they have to put food on the table and they have to pay their rent every month. And so we were very pleased that we were awarded a grant from the Laura and John Arnold Foundation to do a randomized trial of reimbursement of lost wages for potential living kidney donors. And that clinical trial is underway now. What we hope to show is that the program making available to those who randomize to the opportunity for lost wage reimbursement will bring the invisible donors out into the light and enable them to be actual donors, so that the recipient pool in the so-called treatment group will end up in the higher living donor rate at the end of a year than those who are not given that opportunity.
Dr. Sung: In addition to being an ASTS president, you are also a recipient of the ASTS Mentorship Award. I know that you are very proud of the legacy of trainees in the University of Michigan fellowship program; can you talk about your mentoring activities?
Dr. Merion: To me the whole point of being a transplant surgeon was to make the field better, to make the outcomes for patients better, to improve our understanding of the scientific underpinnings of what we do. And throughout my career I’ve focused on trying to do that, with the knowledge that I’m one person at one time, and if I have an influence and I have an impact, it will be for a finite period of time.
So when I wake up every day, I think to myself: I’m very fortunate. I have healthy parents, who were actually able to join me at my presidential year and join us at the San Diego Zoo for my presidential dinner at ASTS. I could see on their faces, in their eyes, how proud they were of their son having achieved the presidency of the American Society of Transplant Surgeons. I also of course had one of my two children there; our younger daughter was in Argentina going to school at the time and couldn’t join us.
And when I think about my family and I think about generations of my family, I also think about generations in transplantation. I learned from my mentors. I certainly learned from Doctor Turcotte, Doctor Campbell, from my major mentor Roy Calne who when I was first met was Prof, or Professor, Calne and later on became knighted. I still remember when I first saw him the first time after he had been knighted and I said: “Prof, do I stop calling you prof, do I call you sir now?” And he said, “When it’s you and me, you can just call me Roy” [laughs]. And I look to my mentors ahead of me, but I also look to those like yourself and so many of the fellows that I’ve had the opportunity and privilege to train and to train with and to learn from. Because to me mentorship is not only about the transfer of knowledge and wisdom from the mentor to the mentee, but it’s learning from your mentees. And I really feel that was one of the reasons, maybe the major reason, I was chosen for the immense honor of being one of the first recipients of the ASTS Mentorship Award. I haven’t won very many awards in my career, but even if I had, the ASTS Mentorship Award would clearly be the crown jewel as far as I’m concerned.