My Life in Medicine
I don't much
like autobiographies, with the possible exception of Benjamin Franklin's.
However, I have told this story a number of times and it seems to interest
each listener. Thus, I decided to write it in the form of a partial
autobiography, covering my professional life from the late '60s to the
late '80s. Like all good stories, some of this is true. I usually omit
people's names from my writing, but in this piece I stray from that
rule several times. Be assured that all that I write about those friends
and colleagues is true, or at the least, is the way it seemed to me.
I owe my "life in medicine" to Dr. Christiaan Barnard. Well, perhaps not directly, as he and I have never met nor corresponded. But there is no question that if he had not performed the first successful heart transplant in late 1967, my career would have turned out differently.
At that time, I was working for the General Electric Company in a group which designed, assembled and tested radio-isotope fueled solid state electricity generators to be use on satellites and manned space missions. Some of our hardware is on the Moon, having been carried there by five Apollo landing missions. The space program did not seem to have much future, since JFK's goal of landing on the Moon before the end of the '60s was on the verge of being achieved. Despite talk of space stations and a mission to Mars, civilian space programs were contracting rapidly and military efforts similarly diminished when the US decision was made not to militarize space. Simply put, our group was looking for work!
One idea was to develop a nuclear powered heart pacer. This was early in the use of heart pacers and their batteries had to be changed every 2-3 years; not very satisfactory for patients who began to feel that they needed zippers installed in their chests! Other more visionary groups were focusing on totally implantable artificial hearts when we began to think about such things and there was, for that time, a large federal program to support such research and development efforts. So preliminary work began and I drew the assignment of learning about appropriate "biomaterials": materials which could be used safely in devices which were to be implanted in the human body. I write biomaterials within quotation marks since the field was so new then that we couldn't even agree on its definition.*
I must digress briefly here. I had graduated from Cornell University in 1961, with a degree in Physics, and had been working in various industrial companies before coming to GE in 1965. By 1966, I had become dissatisfied with my work there and had begun a masters degree in night school, with the eventual aim of returning to full time study for a Ph.D. But it is fair to say that, while there was "push" to change, I felt no strong "pull" from what was to be the next thing.
As I began to study biomaterials, I became fascinated. I had always avoided biology for the "harder" physical sciences: now, I had the need to know, it appeared, almost everything! I later came to describe the intellectual field of biomaterials as a "simple" one, which included all of biological and physical science, as well as engineering and medicine. Or, more simply put at the dinner table one evening, "Everything is biomaterials!"
There seemed to be no end of unsolved problems. Here was a field in which even the simplest questions had to be answered by, "We don't know." It seemed almost literally true that by the time Neil Armstrong took his one small step onto the Moon, we knew more about the backside of that celestial body than we knew about the inside of the human body, at least in the quantitative terms that engineers could understand and use. Although there was much known about human physiology, the overwhelming paradigm was chemical and focused on illness rather than wellness: for each disease, there was a cause and for each cause, a curative magic bullet, either known or waiting to be discovered. We were just beginning to understand the implications of Watson and Crick's deciphering of the DNA code and ideas of cloning and gene therapy were viewed as wild-eyed dreams of science fiction writers. And manufactured permanent implants were still novelties.
And among the mysteries of biology, perhaps the greatest was how blood functioned (and malfunctioned!). If our ignorance about the human body was massive, that about blood was near total. Yes, we knew about blood groups and sub-groups, we appreciated the technical needs for successful blood transfusion and there had been many efforts, mostly unsuccessful, to produce artificial blood vessels which would remain open and useful in the body for long periods of time. Leo Vroman* and Ed Saltzman were in the midst of their groundbreaking investigations which revealed just how difficult it would be to provide artificial materials which could remain in contact with human blood for long periods of time. But we had the arrogance to believe that providing long lived heart pacers, circulatory assist devices and total artificial hearts was possible and would be only a matter of a few years of development and testing.
Against this background, on December 3, 1967, Dr. Barnard performed the first "successful" heart transplant at Grote Shur Hospital in South Africa. Although the recipient lived only 18 days, this event had a great impact on me:
First, federal funding for artificial hearts and related devices dried up overnight. The US Congress, in its infinite wisdom, argued that if natural hearts could be transplanted, there was no need to develop artificial ones. History has proven this to be false. Today, when such operations are nearly routine and successful in many patients in the long term, demand still outstrips supply by a ratio of 5-10 to 1.
Second, although I did not fully realize it at the time, this procedure embodied all that was and remains socially unacceptable about organ transplantation. In a country in the coils of apartheid, Barnard had chosen to implant the heart of a young black man into Louis Washkansky, a white middle class Africaans retired postal worker. In this act were contained the seeds of one of the central issues, even today, of organ transplantation.* The donors tend to be young, lower-class and disenfranchised while the recipients are older and privileged. Some of this is inevitable, since the young are more likely to die with healthy organs and the old to need them to continue life.
The only solution seemed to be through engineering! I was much younger and considerably angrier, in general, then than I am now. Thus, I set out for the University of Pennsylvania, to learn biomaterials and to solve a classical problem: that of making materials which would touch flowing blood without producing clots or other damage. This is the so-called "blood contact problem."
Thus, in fall of '68, I found myself a full-time student again. I was somewhat older than my class mates, with a wife and 2 and 7/9 children (Matt, our youngest, was born that November), a mortgage and, already, debts. There seemed no end of work to do and things to learn. And I was acutely aware that, at 29, I had to work harder and things took longer than when I was 19.
My first year was very difficult - I will draw a veil over it and the events which moved my focus from matters cardiovascular to ones orthopaedic. But it was fortunate that they occurred: today, 30 years later, the general blood contact problem remains unresolved and I might have become the world's oldest living graduate student!
However, by summer of the next year I had met Dr. Carl Brighton and was deeply immersed in biomaterials aspects of orthopaedic engineering, a field which I would pursue for the rest of my professional career. I must write briefly about Carl, as he was first my mentor than my colleague over two decades. He was born and grew up in Pena, a small coal mining town in southern Illinois. His father had been a minister, most of his siblings went into various religious pursuits but Carl elected to go to medical school and orthopaedic residency, joined the Navy as a career professional and then, after a Vietnam hitch, while stationed near Chicago, earned a Ph.D. He was one of the first of a generation of research trained MD/PhDs who transformed orthopaedic surgery from injections and bone setting to the modern knowledge based discipline of musculoskeletal therapy and reconstruction which we take for granted. Perhaps the most important milestone in his career occurred in mid-1967 when Dr. Edward Ralston, then chief of Orthopaedic Surgery at the University of Pennsylvania, where Carl had done his residency, persuaded him to leave the Navy and return to Philadelphia to organize an orthopaedic research laboratory.
Carl and I took to each other at first sight and I immediately began to help out in his then quite small research group. In the fall of '71, when I had completed my doctoral studies, it seemed natural that I join the department and work with him in the laboratory. I did this, rising to tenured full professor in '80, and remaining there until my life in medicine essentially ended in '88 when I accepted the Hunter Chair in Bioengineering at Clemson University.
I could write at length about my work with Carl in what later became the McKay Laboratory of Orthopaedic Surgery Research. Much of it was interesting and some of it was unusual. But there is one aspect which was totally unexpected and that I still look back on with a sense of wonder.
During my graduate training, I had attended weekly "grand rounds," where patients and their clinical conditions are presented to the faculty and students for educational and consultative purposes and had spent at least 1/2 a day a week observing surgery. After joining the faculty in '71, I continued both practices, the latter especially as conversation across a patient during surgery proved to be one of the most effective ways of teaching engineering principles to young surgeons in training. Those were simpler days than today: I usually "scrubbed in," and as time went on, took more and more of an active role in the mechanics of the surgery itself.
You may be concerned about this: it seems to be practicing medicine without a license. In reality, medicine then, as it is today, is a team sport. While the doctor or the surgeon is both coach and quarterback, calling the signals and taking responsibility for the outcome of each play, even receptionists make implicit medical decisions when they schedule appointments for patients. In each case, as in mine, the work is under the direction of a physician, who is assured that training is commensurate with activities and responsibilities.
All of this seemed fun and good pedagogy. But my career took an interesting and, as I indicated, unexpected turn in '78 when I took my first sabbatical. The previous year I had met another giant in modern orthopaedics, Mr. R.S.M. Ling, who was then the clinical chief at Princess Elizabeth Orthopaedic Hospital in Exeter, UK. Robin Ling, although not research trained, has an acute and thorough going interest in engineering aspects of total hip and knee replacement. Unusual for a clinician, he turned up at a variety of non-clinical research meetings in the US. I met him at a week long meeting in New Hampshire. We found we had a lot in common, beginning a more than twenty year series of discussions about orthopaedics. Occasionally, the telephone still rings at odd hours and it is Robin wanting to talk over some new idea.
He arranged for me to be appointed as an Honorary Consultant in the National Health Service. We arrived in Exeter in January and I was thrown immediately into a swirl of ward rounds, conferences and surgery. It had been my intention to be resident in the hospital, to observe and learn and to collect some interesting case material for use in teaching. However, I saw that the staff were literally under siege, with a clinical load 5-6 times that usual in the US. And Robin quickly found out that I knew enough clinical orthopaedics to be useful. By the time I returned to the US, I had, putting the bits and pieces together, "done" a good number of joint replacement and other orthopaedic operations, always working with Robin or one or more of the surgeons in training. It was a thrilling experience and I was not happy to see it end that summer.
I still remember my first long conversation with Carl about my sabbatical. I recounted this story and he became unusually quiet. Then the conversation continued thus:
Carl: What would you like to do now?
Myself: I'd like to go on operating.
C: Well, we could give you time off to go to medical school.
M: I don't want to go to medical school.
C: If you took the National Medical Board Examinations, we could probably let you join the residents and...
M: I don't want to join the residents.
C: Well, what do you want to do?
M: I'd like to go on operating (please!).
Finally, after much discussion, it was arranged for me to have a temporary position as a consultant in our local veterans hospital and I continued to assist in surgery and, as I insisted, to be paid for my efforts. It proved to be an even better teaching situation than before, as the residents and medical students paid more attention and I was able to address more complex problems and clinical situations. The following year, I was given a regular part-time career civil service appointment which I continued in for more than five years until other demands on my time led to a decision to retire from clinical medicine.
One of the consequences of this experience was to make me very comfortable with medicine, hospitals and physicians and surgeons. Even today, when I speak with medical professionals for the first time, many assume that I am one myself and ask where I was trained, where I practice, etc. In addition, it provided a unique insight which I was able to bring to my engineering research and teaching at Clemson University and, later, to my industrial and legal consulting practice.
The moral and ethical problems of organ transplantation remain unresolved but I thank Dr. Barnard for my life in medicine.