Friday, November 21, 2008
Transplant gone wild
The University of Pittsburgh (UPMC) has been the center of the transplant world for almost thirty years, ever since Thomas Starzl MD assumed command of the transplant program there in 1981. Dr Starzl is the father of modern liver transplantation. He performed the first one in 1963 (patient died shortly thereafter) in Denver, CO and also the first successful one in 1967 (graft functioned for 13 months). During his time as the chief at UPMC (he retired from surgical practice in 1998, but continues to be active in research) a legion of transplant surgeons learned the techniques that Starzl invented and honed, and have dispersed themselves across the country to teach a new generation (I actually was privileged to learn from one of them in Chicago at Rush University). So it's a bit of shame to see the program now attracting some negative publicity regarding this Amadeo Marcos business.
Dr Marcos was hired in 2002 by UPMC to head the transplant program with a mandate to increase surgical volume. During his 6 years there he was able to successfully fulfill his boast of doubling the number of liver transplants UPMC performed yearly. But the means to achieve such ends raised some questions, not the least from Dr. Starzl himself. The allocation of transplantable livers in this country is based on a recipient's MELD (Model for End stage Liver Disease) score, i.e. need rather than time that the patient has been on the list. The sickest patients get get first choice, in other words. Seems fair and balanced, right? So how could somebody manipulate the system?
Well, it became evident that Dr Marcos was putting bad livers in patients who weren't that sick. Let's say your patient is number 25 on the MELD list. A liver becomes available. But it's a bad liver (old patient, prolonged ischemic insult prior to harvest, steatotic, etc) and transplant surgeons representing patients 1-24 on the list have all turned it down. It's a terrible liver, they say. Odds are, it won't work all that well. Your patient isn't that sick. In fact, said patient is living independently at home and was buying groceries for her family when you called her to tell her a liver was available. Nevertheless, you book her for the OR that night and stick that liver in her anyway.
On top of that, Dr Marcos was also a serial womanizer who liked to beat his girlfriends. But that didn't seem to bother too many people, especially not the executives of UPMC. After all, Dr. Marcos had fulfilled his pledge in doubling the volume of liver transplants performed. This productivity coincided with a very profitable time at UPMC. To this day, it brings in over $7 billion in annual revenue. The CEO, Jeffrey Romoff, nets a cool $4 million annual salary. UPMC headquarters are now located in Pittsburgh's tallest skyscraper downtown and employees are flown to distant rendezvous in a leased corporate jet. All this from a non-profit institution.
It seems that the breaking point actually centered around Dr. Marcos' claims with regard to the safety of his living donor liver transplant program. Living donor liver transplantation entails removing the right lobe of a completely healthy person's liver and reimplanting it in someone with a failed native liver. Dr. Marcos then published data that exaggerated the safety of such procedures done under his guidance. Now let's examine the ramifications of this. We have a renowned transplant surgeon meeting with a prospective living donor and eminent surgeon explains to the donor that his complication rates both for donors and recipients of the proposed procedure are much lower than the quoted national averages, when the reality of the situation suggests the opposite. There is an implicit trust between patients and doctors that I have addressed in other posts. The minute you start to betray that trust is when you cross into the purview of unethical behavior and destroy the foundations of everything we try, in good faith, to do for our patients.
Fortunately, the old lion Dr Starzl liked to keep a close eye on his baby at UPMC. He grew apprehensive of Dr. Marcos' claims. His subsequent investigations threatened to expose the truth but he was "encouraged" to withhold publishing his findings until they could be confirmed by an outside review committee. (Yes, the father of liver transplantation was told by his home institution to bury unsavory findings until someone else could look over his data. Basically this is like having the Paris Review inform Gabriel Garcia Marquez that they wouldn't be able to publish his latest short story until it had been properly vetted by an outside authority.) Of course the findings were corroborated by the outside committee and, ultimately, Dr. Marcos was given his walking papers in May of this year......