Lessons Learned: The Puzzle People

Memoirs of a Transplant Surgeon

From a progress studies perspective there are a few lessons to be learned.

One is obvious: there were simply more low-hanging fruit in that era, which accounts for the remarkable progress from 1960 to 1990 in transplantation: for example, the transition of patients with kidney failure simply dying to having primitive dialysis machines to transplantation were step function changes in that disease. Going from having just steroids and radiation therapy in the immune-modulating toolkit to many more (check out the Wikipedia page on immunosuppressive drugs—there are a ton!) was also a huge step. And yet, each step forward, giant though it may seem, is generally increasingly marginal. 6-MP and steroids made living related kidney transplants possible; cyclosporine added unrelated kidneys, cadaver, kidneys, and livers; tacrolimus improved survival further and made multi-organ and islet cell transplants possible. Outcomes today for liver and kidney transplants are pretty good, though much room for improvement remains. However, outside of radical changes like lab-grown organs that evade immune rejection entirely, improvements are not likely to be true revolutions in care.

Two, the talent that was being funneled into surgery seems quite strong. As a qualitative observation, the extremely high work hours and complete lack of work-life balance filtered for the kinds of extreme obsessives that are good at driving fields forward. On the other hand, minorities and women were largely excluded from medicine in large numbers till probably around the 1970's, which would drive down the pool of people eligible for those careers. My guess would be that the latter effect should outweigh the former, and that the level of talent then was lower than it is now, but I’m not sure. I know a fair number of workaholics in medical school, but nobody approaches Starzl's level of work. I also know a fair number of surgeons and physicians and they don't seem to work nearly hard as Starzl did-- but I would welcome any input or correction on this point. In general, I don’t know anybody in any field who works that hard.

 As a side note: before anybody accuses Starzl of glorifying this workaholic culture, rest assured he provides ample evidence of its dark side. By my count, at least three members of his team at Denver and Pittsburgh died in car accidents in their 20's, likely caused in part by too little sleep. He also describes in frank terms the dissolving of his first marriage, and though he doesn't talk about it, it is hard to imagine him spending much time with his kids in his 30's and 40's, when he was working something like 100+ hours a week.

Another argument to explain that level of hard work (which I’ve heard Tyler Cowen make a number of podcast appearances) is that leisure has gotten so much better since the 1960's that forgoing leisure back then was not as costly as it is now, in the era of video games, cheaper travel, better restaurants, etc.

From a history of science perspective:

There are some interesting examples of what could be called "missed evidence". For instance, in the early 70's Starzl had demonstrated significant reduction of circulating cholesterol with a surgical maneuver called portal diversion, in which portal blood (the liver has a dual blood supply) is diverted away from the liver, depriving it of portal blood, and causing mild liver disease. However, around the same time, work by Goldstein was pointing away from the liver as the regulator of cholesterol. Later on, Goldstein published other work showing the liver was the most important regulator of cholesterol levels, but for about a decade, there was a general lack of interest in Starzl's results pointing towards the liver because other data supposedly showed the liver wasn't that important. Put in more abstract terms, contrary clinical evidence in humans was somewhat neglected until a new paradigm could explain it and other evidence.

Other miscellaneous observations:

-transplantation was enormously expensive and not that successful in the early years. Early innovations are often enormously expensive and inconvenient but improvement will follow and bring down cost and difficulty. Many rate-limiting steps can be bypassed. Many examples of this in liver transplantation: preservation, the surgery itself, immunosuppressants, medications for immunosuppression side-effects, an algorithm that can facilitate donor chains, etc. Some insights into modern transplant can be found here on a recent podcast with Peter Attia and a transplant surgeon.

-politics and turf battles within institutions matter a great deal. Starzl left his post at Denver in part because of this! Disagreements over how research and clinical funds should be allocated, disagreements over the ethics and PR of performing experimental surgery, all of these can hinder scientists.

-The opposition of the general public and of ethicists to a specific innovation tends to disappear once successful examples appear. A similar phenomena occurred with IVF, as chronicled in A Matter of Life.

-Starzl has an unfavorable view of the FDA’s regulation because his experience was with large-effect interventions that mostly worked. He didn’t see all the attempted miracle cures that crashed and burned. More on the FDA here.

-many low-hanging fruit in medicine could be picked by medical students and residents in the 1950’s and 60’s. A complete lack of regulation played a part but mostly a lot of easy stuff hadn’t been tried so it wasn’t too hard to improve on existing knowledge.

- part of the medical progress story from the 1950’s to 1970’s is that the number of medical schools grew quite a bit because policy makers realized they would need more physicians. The expansion of schools and positions meant it was easier for young and middle age physicians to move into positions of authority, because the number of administrative spots was increasing.

-Lots of medical occupational hazards we take for granted now were real dangers back then. Plenty of surgeons died of hepatitis or needed transplants themselves because of infections from patients.

Surgical training was absurdly demanding back then. On Hopkins training:

It was a seller's market. The salary for the internship year was zero, and after this it was symbolic only. During my fourth and last year I reached the level of$36 per month. I had arrived in Baltimore with $500 in my pocket from a Borden Research Prize. Even without this advantage, conditions were workable for an unmarried house officer because the food was free and outstanding, and there always was a place to sleep if the time could be found. For some it was heaven, and for others hell. I found it to be purgatory. There were no women nor any black interns or residents during my four years there. The social climate was southern.

Incidentally, another famous surgeon, Micahel DeBakey, was also famously hard-working:

Even in his 90s, Dr. DeBakey arose at 5 a.m. every day, wrote in his study for two hours and then drove, often in a sports car, to the hospital, where he stayed until 6 p.m. After dinner, he usually returned to his library for more reading or writing before retiring after midnight.