In Their Own Words:
Organ transplant didn't belong in a single department. It wasn't simply a surgical specialty. It wasn't a specialty that belonged in medicine. It wasn't just an add-on to urology; it wasn't an add-on to gastroenterology and liver transplant; it was a thing of its own that required all these things but didn't really belong in any one department. And to put together an administrative unit that was recognized by the university that would have some clout, that would have all the resources of the College of Medicine and the hospitals that were going to transplant programs run through the center, whether it was hiring a new hepatologist, a new cardiologist to do heart transplant or get the lung transplant program off the ground or fight the SRTR with the kidney program, whatever it might be, that was the administrative purview or should have been the administrative purview of the transplant center. There wasn't any at the time; there wasn't a model to follow, and it was plowing new ground and I must say, it was like plowing new ground in February in Minnesota. It was a little tough.
Ronald M. Ferguson is Professor of Surgery Emeritus at The Ohio State University. A medical graduate of Washington University in St. Louis, Dr. Ferguson completed his surgical residency and transplant fellowship at the University of Minnesota where he also earned a PhD in immunology and served on the surgical faculty. In 1982 he moved to The Ohio State University to direct its Division of Transplantation; he rose to become Chairman of the Department of Surgery at Ohio State in 1993. Dr. Ferguson has held numerous leadership positions in transplantation and academic medicine including Vice President, Secretary and Councilor of The Transplantation Society and President of the Society of University Surgeons. He has chaired an NIH Study Section as well as the Veterans Administration Merit Review Board for Surgery. Dr. Ferguson has held a number of committee positions with the United Network for Organ Sharing, which he also served as a Director. The ASTS elected Dr. Ferguson as its President for the 1997-1998 term. Author of more than 350 publications on topics in organ transplantation basic and clinical science, Dr. Ferguson has also written poignantly on quality of life issues affecting busy academic physicians.
Dr. Ferguson: I am Ron Ferguson. I'm a transplant surgeon. My current position is professor emeritus at Ohio State University.
Interviewer: How and when did you become interested in transplantation surgery, and where?
Dr. Ferguson: I was a resident at the University of Minnesota in general surgery. I'd come there because I was wanting to be a heart surgeon and at the time, in the late sixties and early seventies, Minnesota was a very good place. John Najarian was the chairman there and their tradition had it with residents that after your second clinical year of residency, you went in the lab for one, two, three… however many years. I was at the VA on a second-year resident rotation and Dick Simmons was coming out as the attending. No resident had ever gone through Dick Simmons' lab, but I had a great deal of respect for Dick; he's a very smart man. And at the time he was really the intellectual godfather of transplant, certainly at Minnesota, and extremely well-respected worldwide. He was also a very good scientist. He was on the immunobiology study section as well as the surgery anesthesia and trauma study section that did all the transplant grants. So I went into his lab, talked to him about transplant, and did transplant immunology for three years and got a PhD with him as my advisor. That really got me interested, and I was captivated by the blend of basic science, clinical, and policy and there's so many things about transplant that are unique to transplant if a surgeon wants to broaden his scope and become involved.
Interviewer: Okay, tell us a little bit about your clinical career.
Dr. Ferguson: I was a transplant fellow in 1979; 78-79. And I had just finished my chief residency at Minnesota and actually was the first resident to do his internship, residency, lab work, and transplant fellowship at the University of Minnesota, since Najarian was there. Dave Sutherland was there, but he'd been at West Virginia, done some training there and been in the army, and he'd come back, but I was the first one to go through that whole program. And my fellowship in transplant was in 78-79 and January of 1980 I joined the faculty at Minnesota. And at the time, it was John Najarian, Dick Simmons, Dave Sutherland, and me, which meant I did all the work, especially between about six at night and about six in the morning. (Laughing) I was there for three years—well, two years and ten months—and then left Minnesota and went to Ohio State in October of 1982 and have been there at Ohio State ever since, building and trying to establish another little Minnesota in the Big 10.
Interviewer: Let's talk about your time at Ohio State ever so briefly as a transplant leader, then as chairman.
Dr. Ferguson: I went to Ohio State in October of 1982. I was recruited by Larry Carey, who was the then chairman of the department of surgery to take over a program that had begun in 1967 by Jim Cerilli. It was a smallish program, doing about 35 kidneys a year at the time, in 1982. Jim had left; there was no one there. And I might say Jim Cerilli is a wonderful man, but he had a rather abrupt style to him and had alienated and actually pissed off every nephrologist within 150 miles of Columbus, (laughing) which made starting the program somewhat difficult. But we got it going. And in the early days, I was there by myself for about a year and it was a lot of work. It was a lot of work. We did 150 kidneys the first year I was there and about two-thirds of those were living donors.
Within the first year, I recruited a couple of coordinators from Minnesota. The first recruit I made was Charlie Orosz, who I had worked with and known and was a dear friend and colleague at Minnesota. And Charlie came down, he was going to run the tissue typing lab as well as set up the transplant therapeutic immunology laboratories, which broadened the scope of what they were going to do and extended a lot more of the basic immunobiology to transplantation. Then I recruited Bruce Sommer, who had just finished his fellowship, to join us so there were two surgeons and Charlie. Tried to get the nephrologists involved, tried to get internal medicine involved, but they really, really weren't interested in transplant. It took a long time, but after about six years I got Fernando Cosio, who was one of the nephrologists there and had been at Minnesota; I was a fellow and he was a nephrology fellow at the same time.
He became interested in transplant and really set up along with us, transplant nephrology at Ohio State. He lasted there in transplant nephrology about five years and then left to become chief of transplant nephrology at the Mayo Clinic in Rochester. Charlie Orosz, who had a wonderful career at Ohio State, ended up being president of ASHI, doing some absolutely seminal work in mechanisms of rejection using a mouse heart transplant model. Unfortunately he died in 2005, so with the departure of Charlie and the leaving of Fernando, things changed rather dramatically at Ohio State.
We also set up a fellowship program the second year I was there. It was actually a brainchild of John Najarian when he was president of the ASTS to establish some criteria, as long as the American Board of Surgery wasn't going to give it a certificate of special competence, and oversee it with the RRC. The ASTS decided to do that in the Education Committee, which John Najarian chaired when they set up the program. So I think Clyde Barker and Jerry Turcotte came down to review our program and what Bruce and I had with Charlie there and with the coordinators in the organization we'd tried to put together, and said, “Yeah, I think you guys can probably train somebody.” So Mitch Henry became our first fellow and parenthetically, there is an interesting story about Mitchell. He was supposed to go down to Grant Hospital; that was the plum private rotation, where they did a lot of general surgery and a lot of vascular, and his girlfriend at the time, ultimately became his wife, was head of the vascular lab; she was a nurse in the vascular lab down at Grant. And he thought that was going to be just duck soup. Larry Carey talked to him and said you're going to be the first fourth-year resident to be on the transplant service with this new guy that just came to town. Mitchell didn't want to do that at all; he wanted to go down to Grant.
So he came on the service with a chip about the size of this building on his shoulder. (Laughing) But I think Mitch is a very bright guy and if you tweak enough, he has a very keen sense of curiosity. And he became very curious about transplant and ultimately decided after his chief residency here to do the fellowship in transplant rather than doing it in vascular surgery and stayed on the faculty and is still here, and I believe is the next president of this austere group.
Larry Carey left; there was a good bit of turmoil at Ohio State at the time. Michael Swango was there. Michael Swango was a resident that was literally assassinating patients. Ultimately currently is in federal prison and was the topic of a book called Blind Eye. There were several other things, lawsuits, faculty suing the university, there was no chief of cardiac surgery, orthopedics, or urology, all of which were in the department of surgery. Larry left and they wanted me to become acting chairman and all I had to do was build cardiac, urology, and orthopedics, calm down the press, and write a practice plan and take 17 independent corporations and put them into one single department group, which we actually did do over the next three years.
Then Olga Jonasson was named the chairman of the department of surgery and she was there from 87-93 and then I became chairman and was chairman from 1993 through 1999. So I was chairman of the department of surgery and still chief of the transplant program.
Interviewer: And then you started the Institute at Ohio State, I think.
Dr. Ferguson: We did. After I was chairman, went back to transplant and at the time—this would've been about 2001, 2002—I didn't think transplant was organized the way in academic medical centers that it should be. I had many talks with many people in the ASTS about this, as well as in the AST. Organ transplant didn't belong in a single department. It wasn't simply a surgical specialty. It wasn't a specialty that belonged in medicine. It wasn't just an add-on to urology; it wasn't an add-on to gastroenterology and liver transplant; it was a thing of its own that required all these things but didn't really belong in any one department. And to put together an administrative unit that was recognized by the university that would have some clout, that would have all the resources of the College of Medicine and the hospitals that were going to transplant programs run through the center, whether it was hiring a new hepatologist, a new cardiologist to do heart transplant or get the lung transplant program off the ground or fight the SRTR with the kidney program, whatever it might be, that was the administrative purview or should have been the administrative purview of the transplant center. There wasn't any at the time; there wasn't a model to follow, and it was plowing new ground and I must say, it was like plowing new ground in February in Minnesota. It was a little tough. (Laughing)
Come to find out that—and I think Dick Howard mentioned this in his presidential address several years later in attempting to do the same thing in Florida—the two adversaries that become very passive-aggressive are the chairman of medicine and the chairman of surgery. So you're trying to put something together that they see as a threat and people tend to retreat into the politics of self-preservation as opposed to what's better for the institution. And it creates some interesting conversations, let me put it that way. But in the end, we did establish a center and I did run that center for the first several years. We did manage to bring the thoracic people into the center. We managed to have our own quality control, our own things, and it became functionally a department with faculty from many other departments that were part of the center and the center was providing resources to all those other departments to be able to recruit them. Bob Higgins was recruited to run it now and I'm sure he will take that concept and the foundation that's already been lain out there and extend it much farther.
Interviewer: Let's go to the ASTS.
Dr. Ferguson: Actually, the ASTS was one of the things that sort of tweaked my interest because the American College of Surgeons was down in Miami in 1974 and there was an organizational meeting at the Fontainebleau Hotel.
And what had happened is H.R. 1 had been passed in 1972 and HHS or Health and Human Ser- vices, Health, Education, and Welfare, HEW at the time, had no one to really talk to in the surgical community, in the transplant community. They had nephrologists for dialysis, but once the end-stage renal disease program was established, they wanted some sort of trade organization that they could deal with issues of reimbursement, with all kinds of things that were implicit in Medicare and Medicare reimbursement for transplant patients. So they talked to Fred Merkel and Aaron Bannett, and they said would you put together this organization, which they did and they really invited Roy Calne to come over from England and to help and talk a little bit, so there was this organizational meeting. And at the organizational meeting, there was a lot of discussion and that organizational meeting, I believe, elected Tom Starzl the first president and Tom was very much involved, as was Jerry Turcotte, as I believe the first chairman of the membership committee, but I'm not entirely sure about that. But I was at that meeting because I was a resident at the time and I was giving a paper at the surgical forum because I was in Dick Simmons' lab. And I tagged along with everybody and went to the meeting and I was like this little mouse in the corner, listening to all this stuff and it was fascinating. So that was my first exposure to the ASTS, probably in its embryonic stage, the first organizational meeting. Then, as part of the, I believe we were called, the Minnesota Mafia—we always thought that John Najarian should buy us all gold jackets and then have a football and a scalpel as a little logo on our jacket because every year for the first five to eight years of the ASTS meeting, there were a host of papers from the University of Minnesota, mostly given by residents or the younger people—I was one of those, gave quite a few papers at the ASTS and became involved. And when I started on the faculty at Minnesota, I started on a lot of the committees, on the Program Committee, on the Scientific Studies Committee, on a number of committees. And then was secretary and then became president of the ASTS in 1998 at a very turbulent time because there was a lot going on with policy issues. The final rule was being written and there was an enormous controversy about it and actually a lot of passionate fighting between transplant centers and Donna Shalala and there was lots going on as well with the ASTP at the time. The physicians were growing, so there were moves at the time that I was president to try to form a single organization. And we put together a joint council. Hal Helderman was the president of the ASTP at the time and I was president of the ASTS. We put together a joint council, and so the first joint council meetings were held then and were really trying very hard to get a single organization that could represent all the issues of transplant in the United States. It actually didn't work out, but we tried quite hard. (Laughing) I think the enlightened self-interest of the physicians and the surgeons sort of got in the way. But it didn't ultimate in a single organization.
Interviewer: Let's go to a little bit lighter side of things. Uh, I know especially knowing you and Mitch as I do, that there must've been some interesting moments…
Dr. Ferguson: (Laughing)
Interviewer: In the operating room. So, just recall for us, if you would, some memorable moments in clinical surgery, in or out of the operating room, but some of the fun things that were part of the work.
Dr. Ferguson: Oh, I remember one. Mitchell actually is quite intense and very serious in the operating room. He's also an exceptionally good surgeon. But there is one story that is kind of interesting. It doesn't involve Mitch as much as it involves R.J. Tesi, who was a fellow with us, but then stayed on the faculty. R.J. was doing a liver transplant, and he'd finished the anastomoses and when he'd lay the liver back down, it would become engorged like there was some sort of venous obstruction and it just wouldn’t sit there very well. And he kept trying to figure it out and he was trying to tack it up and he was trying to do this and he was trying to take the falciform ligament and tack it up and do this. So finally, he got a breast prosthesis. (Laughing) And he took that breast prosthesis, the silicone breast prosthesis… it was silicone; it wasn't even a saline injection, and he tucked it in behind the liver, like you'd shim up a table or something, and it propped it up. Oh, there's the usual stories about throwing instruments and this, that, and the other thing and temper tantrums but that was probably one of the more colorful things because I was in the room, Mitchell was in and out of the room, everybody was… He was getting advice from everybody on what to do. He finally just took this breast implant and packed it back together. The guy did fine. (Laughing) I don’t know to this day whether that breast implant is still there or not, but it was rather creative.
Interviewer: We usually ask if you want to chat a little bit about how transplant impacted family life for good or for ill.
Dr. Ferguson: You know, that's a really interesting question and it's interesting that you would do that. Of all the specialties, transplant is a particularly demanding mistress; there is no question about that because it doesn't matter if it's Christmas Eve or if you’ve got opera tickets—if there's a donor or if there are organs, they have to be put in, you go do it.
There were many Christmases. At a winter meeting, must have been four years ago or so, maybe five, when they asked me to give a talk about how to be a "successful faculty" and I gave the talk and there was a question and answer period and somebody, a young woman—I don’t even recall who it was—stood up and said what would you do differently if you had to do it over again? And I looked at her and I thought a little bit and I said, “I tell you, I'd go to a lot more soccer games.” And they didn't quite know what I was talking about and I said, “If you get up at 2:00 in the morning and go in and do a kidney, or if you do it at 4:00 in the afternoon, there aren't going to be very many people that remember that. But, if you go do it at 4:00 in the afternoon and you miss somebody's soccer game, they're going to remember that.” So I think it takes a toll on families. None of my kids wanted to go into medicine, for that reason. There was a ten-year period, trying to build the program at Ohio State, where you just didn't…. I remember once, this was before Bruce came to Ohio State, there was a young urologist that had trained at the Cleveland Clinic and he was going to do some cadaveric procurements, because I was the only one there and it was at night, or it was in the afternoon, and they'd called him to do it and he said, “Yeah, I'll do it in the morning. I'll go over there and do it in the morning.” The donor happened to be in Parkersburg, West Virginia. So they called me up and I said that's unacceptable. So I hopped in the car, drove to Parkersburg, did the harvest, took the kidneys back, got one of them in and transplanted and then that young urologist showed up in the operating room the next morning while I was doing the second kidney, telling me that there was a donor and that he was going to go get it. You don't do things that way, and that's why it's fairly demanding in that those demands don't fall on you so much because we're all used to working hard. They really fall on your family.
Interviewer: Let's talk a little bit about where you see transplantation, clinical transplantation particularly, 10 or 15 years from now. What's the future? You and I are winding down; we'll hopefully be around, but we won't be putting the organs in or taking the stem cells out or whatever it is. What do you see?
Dr. Ferguson: Well, with all the genetic engineering and manipulations and stem cells and the artificial matrices that are then turned into organs that's happening right now, the science is going to be spectacular over the next 15 years. Where's that going to go? It's going to result in a new organ source. Whether that is from genetically engineered non-human animals and xenografts as a donor source, whether that's going to be the replacement therapies like they now have for bladders and a variety of other tissues and whether you can ever do that with a liver or with a kidney, and exactly what's going to happen with mesenchymal stem cells and the heart and how they're going to re-scaffold that do things, I mean it's very exciting. But, I suspect it's going to be either these bioengineered new organs that would be replaceable, or xenografts from animals that have been genetically engineered to have human genes in them, that will probably be the source of a good number of organs because the issue is going to be organ supply.
Interviewer: A word about regulatory matters and transplant centers.
Dr. Ferguson: Well, I think transplant, and probably for good reason, is the most highly regulated part of health care. I mean, if the cardiologists and cardiac surgeons had the kind of oversight and regulatory framework that transplant has, first of all, there might be a whole lot better results at a whole lot lower cost. (Laughing) But I think there would be an outcry, just an outcry. It would be almost a revolution.
We sort of grew up with it, and the reason we grew up with it is because of the task force and the task force recommendations to Congress that came out in NOTA in the early 80s, and that was that organs are a national resource. And if they are, then prudent stewardship of those organs needs oversight, and I think that's the difference between transplant and other things. Right now, it's evolving and I think it's evolving in a direction that's becoming probably better than it certainly was in the nineties. Exactly where the regulation is going to end up and how it's going to impact 10 years from now, I really don't know. As the organ shortage becomes more and more and more, and there's more people dying and the results are even better than they've ever been, you really are going to end up with a political problem, and I don’t know how that's going to be solved with regulation until they get a new source of organs.
Interviewer: Is there anything that you want to add that we would perhaps not have asked or chatted about?
Dr. Ferguson: Oh, I don’t think so. Probably will be, 15 minutes from now, but right now I can't think of any specific thing.
Interviewer: Okay. Let's say a final word about the ASTS and your career. You did talk about the early times and your presidency, but in a general sense, you've been out of clinical transplantation for a few years and you're here at the Winter Symposium.
Dr. Ferguson: Right.
Interviewer: You must have some feelings about the organization.
Dr. Ferguson: I think the American Society of Transplant Surgeons over the last 30 years, or since its founding in the mid-70s, has really become the nucleus of the transplant community. At least it certainly was for the first 15 years. And what do I mean by that? As a young resident in the laboratory and then clinically as a fellow, and then as a junior faculty person, it was the forum every year at the Drake Hotel where you'd get together, and I remember in particular Keith Reams and Mark Hardy from Columbia. I was a young resident and yet you'd sit down at a reception or something and they would talk to you, they'd bring you into the community, they would, in a very subtle and informal kind of way, mentor you and tell you what the world was all about and do it willingly, and I think that kind of camaraderie between those coming up and those pioneers in the field at the time was an exceptionally good thing. I wish it was still around, more than it probably is, quite honestly. Perhaps the smallness of the group was the thing that facilitated that more than anything else.
Interviewer: Let's take it another step. This very meeting is put together by the youngsters.
Dr. Ferguson: I think the young people today, just like they were when I was a young person growing up, need the contact with those that are a little more weathered in the field and a little older, and I think this Vanguard Committee that Ron Busuttil set up during his presidency that puts on this winter meeting probably should have a few more old farts in it, and maybe a few organizational things that could facilitate the interaction with some of the younger people. You know, John Najarian is 83 years old and Tom Starzl is 84 years old. They are still sharp as tacks and still have a lot to tell a young transplant surgeon in his early thirties, if they can get put into the right environment to facilitate that sort of thing. So that's the only thing I would do here, but this is a good meeting; that's why I'm here. I think the idea of promoting the young people in this meeting is a very good one.
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