EP. 70: LIFE AND LOSS IN TRANSPLANT

WITH DAVID WEILL

Jul 11

WITH DAVID WEILL, MD

The former director of the Lung and Heart-Lung Transplant Program at Stanford Medicine shares stories of triumph and failure in the high-stakes world of lung transplantation.

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Episode Summary

A lung transplant—taking some or all of one person's lungs and putting them into someone else, giving the recipient years of additional life—sounds nothing short of miraculous. Today, over 2500 lung transplants are performed every year in the US. Still, it's among the most medically and ethically complex areas of medicine. Joining us in this episode is David Weill, MD, former director of the Lung and Heart-Lung Transplant Center at Stanford Health Care. He is also the author of Exhale: Hope, Healing, and a Life in Transplant. Over the course of our conversation, we discuss the challenges of transplantation, including how we find suitable organs, transport them, and decide who gets them. Dr. Weill also shares the high-stakes human drama that accompanies each triumph and failure, why he eventually decided to leave the practice, and the importance of staying connected in the midst of suffering.

David Weill, MD is the former Director of the Center for Advanced Lung Disease and Lung and Heart-Lung Transplant Program at Stanford University Medical Center. He is currently the Principal of the Weill Consulting Group which focuses on improving the delivery of pulmonary, ICU, and transplant care.
Dr. Weill has served in a variety of international and national roles, both in the private and public sectors, and has authored numerous medical articles, book chapters, and editorials. He has twice testified before the United States Senate about how various inhaled occupational exposures affect lung heath. He has also appeared before various state legislatures and has lectured extensively nationally and internationally at major medical conferences and academic medical centers.
He lives in New Orleans with his wife Jackie and their two daughters, Hannah and Ava.
In this episode, you will hear about:
• How Dr. Weill’s early experienced inspired him to pursue a career as a transplant pulmonologist - 2:14
• What a lung transplant entails - 5:51
• The risks of lung transplantation - 8:31
• Stories of successful and unsuccessful transplantations - 11:50
• Challenges of navigating difficult conversations with patients awaiting transplant - 15:53
• A discussion of the organ transplant selection process - 25:24
• Dr. Weill’s reflections on his transition out of medical practice and what it was like to face burnout - 38:46
• Advice on staying balanced and connected with patients, colleagues, and loved whens when dealing with suffering - 45:20
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] A lung transplant, taking some or all of one person's lungs and putting them into someone else, giving the recipient years of additional life they otherwise wouldn't have, sounds nothing short of miraculous. Today, over 2500 lung transplants are performed every year in the US. Still, it's among the most medically- and ethically-complex areas of medicine. Joining us in this episode is Dr. David Weill, former director of the Lung and Heart-Lung Transplant Center at Stanford Health Care. He is also the author of the book Exhale: Hope, Healing and a Life in Transplant. Over the course of our conversation, we will discuss the challenges of transplantation, including how we find suitable organs, transport them and decide who gets them. Dr. Weill will also share the high stakes human drama that accompanies each triumph and failure. Why he eventually decided to leave the practice and the importance of staying connected in the midst of suffering. David, thank you for taking the time to join us and welcome to the show.
David Weill: [00:02:11] Thank you. Thanks for having me.
Henry Bair: [00:02:14] To start us off, can you tell us what drew you to a medical career?
David Weill: [00:02:19] My father was a physician and his friends were all doctors. And I actually used to really look up to his group of friends and to my father personally. He was a pulmonologist that was an academic medicine for many years, and he never encouraged me explicitly to go into the field. But I think just being around it all those years really got me interested. And then beginning in high school and all the way through college, I worked in a hospital as an orderly in New Orleans, and I'm not even sure they have orderlies anymore, but I really got exposed to a lot of medicine even in those early years.
Tyler Johnson: [00:02:56] You know, it's so funny because we hear a number of people tell stories like that. But I have also talked to a lot of people who are not doctors who tell stories like that. But then the end of the story is and after being around medicine that much, there was no way I was going to go into that as a profession. So what was it that you what was it that you picked up on as a young person that then later made you want to go into medicine?
David Weill: [00:03:18] Yeah, I've heard it go the other way too. Tyler And I think it was, you know, your ability to impact patients. I remember when I was working in the hospitals in high school and college, I would sit with some of the patients that were going to go to surgery the next day because I worked the 3 p.m. to 11 p.m. shift. And it was really just that close interaction with patients, you know, that you were meeting them when they were their most vulnerable. And I could see that even somebody like me in high school and college who didn't have really much medical knowledge at all could really impact them just by sitting with them for a little bit and hearing their story and it was that personal interaction that really hooked me in effort of full disclosure. It was not the scientific aspects of the field that drew me in. It was really the one on one interaction with the patients that got me.
Henry Bair: [00:04:11] That patient connection is something we hear a lot on the show and we hope to explore that further. But first, can you tell us what drew you specifically to become a transplant pulmonologist and tell us what this work actually entails?
David Weill: [00:04:25] Yeah. So I got interested in transplant medicine during my internship. I was at Parkland Hospital in Dallas and one of the upper level residents got sick, quite ill actually, and had to be taken off the kidney transplant service. And so they asked for a volunteer from our intern class essentially to do the scut work involved with the operation. And so I got an early exposure to kidney transplant. And I thought, you know, this is the most interesting thing going got to be the most fascinating field of medicine. And in fact, the first night that I was on the service, we did a kidney transplant on a guy that had been on dialysis for 11 years. And when that urine bag filled up, boy, was I excited. I've never been as excited in my life. And so I was hooked on transplant but didn't really want to become a nephrologist, was very interested in lung and lung mechanics and physiology. And I was in the right place at the right time. When the University of Colorado started their lung transplant program in the early 90s, and I was really just hanging around the transplant pulmonologist Marty Zamora, who was doing that work. And he really taught me everything he knew about the field, which wasn't much at that time because it was so new. So it was one of those typical stories that you probably heard before being in the right place at the right time in the early phase of that therapeutic option.
Tyler Johnson: [00:05:51] You know, I think you are the first doctor we've spoken with who is at least directly or principally involved in transplant medicine. Can you just talk us through really for any whether it's kidney transplant or especially lung transplant, which I think is something that most people are just not familiar with? Like, I think most people have kind of heard of kidney transplants. But lung transplant is, I think, something that's pretty unfamiliar to most people. Can you just trace for us? So two things. The first one is, what is that process like for a patient? Like what might bring a patient to need that kind of a transplant? And then what is the process of going through the surgery and then the immediate post transplant period? What does that look like for a typical patient? Let's start with that question.
David Weill: [00:06:36] Yeah, it's a good question. And I think that the four major diseases that we treat in lung transplantation are pulmonary fibrosis, cystic fibrosis, pulmonary hypertension and emphysema. And so those patients have advanced through a medical regimen and through all non-surgical options before they get to see us. And they're generally referred by a pulmonologist who has run out of options. And so that patient is facing certain death, unfortunately, without a transplant. And the only way we would actually expose a patient to the risk of a transplant is if they didn't have any other options. And so the patients that I met during my career are scared. They're feeling like their time is up. And the magic of transplant is, is that we guide them through this process, doing the evaluation, getting them on the waiting list. And as you can imagine, the waiting period is excruciating for patients and their families because they don't know when this big operation is going to happen. And they've essentially walked up to the cusp of death. And then we do everything in our power to give them a second chance. And so I've called it for many years the ultimate reset. And patients, when the operation goes well, which is the vast majority of the time, come out of the. Procedure with a whole new lease on life and to watch them and their families go through that and to see the things that they do year after year. It's always attracted me to the field. It's magical in many ways. It's a tough therapy both for the patients and the people providing it, but it's worth it because you really give somebody back a second chance at their life.
Tyler Johnson: [00:08:31] So what about then, the second question following on that. So part of the process, as you mentioned, is figuring out who is eligible for the transplant and then helping them navigate the complexities of getting onto the transplant list and figuring out when that's going to happen and trying to you know, and it's this very I'm not a transplant physician, of course, but what I have observed watching patients go through transplants is that it's this incredibly strange dynamic in the sense that you can't even get on the list until you're sick enough, as you said, to be on the cusp of death. But then by the time you get on the list, by definition you're on the cusp of death. Right? So you have it's like you have this group of doctors that are trying to sort of you know, it's like you have the grim Reaper kind of knocking at the door and they're sort of trying to bolt the door and keep it closed. Right. And keep that away long enough that they can actually get to the transplant. So that's part of it. But then after the transplant happens. Can you talk us through as the doctor who's supervising the post transplant period, what are the things that you're the most worried about and what are the things that you're having to watch really closely in terms of because I think most many or most of our listeners probably don't have much of any idea about, you know, trying to avoid rejection and what the immunocompromised state looks like and being on immunosuppressive medications. Can you just kind of walk us through sort of what you're having to think about?
David Weill: [00:09:59] The the biggest things that we have to monitor are for rejection and infection. And through the years, 30 plus years that I've been involved in the field, the monitoring of both of those disease entities has gotten better. The medicines have gotten better. But it's not all we have to monitor. We essentially become the primary care physician for the transplant recipient. So while we're focused on rejection and infection, we also recognize that those patients are ours. Now, generally speaking, the patients are really seen in follow up, sometimes exclusively by the transplant center. And so even in your world of oncology, we've got to make sure that we remember cancer screening and we've got to monitor for cancer. Because as you know, when patients are immunosuppressed, the likelihood of their developing all sorts of cancers increases rather dramatically. So we have to work in a way that a primary care doctor would be to make sure that within the hospital system that we actually have people that we can call on to treat some of the medical complications of transplant, whether or not they're oncological or gastroenterology or neurologic. And that's why this is the ultimate team sport. It really is. It's a multidisciplinary effort to keep those patients going after the transplant. So it's a lot to juggle. Patients see us more often than they want to see us. They have to come back for clinic. They have to get blood tests frequently. They have to get lung biopsies. And while many patients would gladly trade that for what was going to be certain death, we also recognize that there's a burden to this kind of therapy and there's a lot of work involved, and we try never to forget that.
Tyler Johnson: [00:11:50] And one last thing on this in this vein, just to paint the spectrum for us of how well and how frighteningly this can go, Could you tell us maybe two patient stories, one story where the person where it was sort of the quintessential thing you hope for, the person really did get a new lease on life and it was just like they they were living in a new body. So could you tell us one story that on the one hand and then on the other hand, could you tell us a story about someone who went through all of the screening and waiting and working and whatever and got to a transplant and then had some kind of a catastrophic problem afterwards?
David Weill: [00:12:28] Yeah, I mean, I have both and I've written about both. And I think every transplant doctor does. But there were young people in my career and I've got one in particular who I call Tina in my book where she had cystic fibrosis. She was facing certain death. She never was able to live a normal childhood and adolescence. And we transplanted her when she was about 19, had never exercised, had never been to the prom, had never had any of the normal childhood experiences that folks have. And we transplanted her and she went on to live 11 years with her new double lung. She hiked in Yosemite all the time. She jumped out of airplanes, much to my chagrin. I asked her not to do that. She got a she got a tattoo of her new lungs on her back, which I also wasn't crazy about. There's something about getting a transplant that makes folks. Want to get tattoos and I'll never understand it. And. She was somebody she was the kind of patient that that we most wanted to help. And you both probably encountered these patients that squeeze every ounce of life out of their second shot. You know, they they have gotten a second shot. It would just be like a patient that you've cured with cancer, I'm sure, Tyler, where they realized that it could have gone the other way. And so they're not going to waste a minute. And she was shot out of a cannon every single day. And I loved her like one of my own daughters.
David Weill: [00:14:11] I was very close to her and her family. And those are the kind of experiences that I'll never forget. But on the other hand, there there was a patient that we transplanted that things didn't go well at the donor hospital. The timing is very important in transplantation. The lungs sat in the ice chest too long. The team was not ready from a surgical standpoint to implant them when they came back to our hospital. And essentially the longer organs sit out of the body, the higher the risk of complications, especially from bleeding. And she ended up having massive bleeding to the point that, you know, there was blood everywhere in her room. It was coming out of her chest. We couldn't control it. And she actually passed away about 12 hours post op. I think we used 111 packed red cells on her during her operation and her early post-operative recovery. And going down the hallway to talk to her parents is something that I'll never forget as long as I live. And they could see it on my face as I came out of the ICU. And the look on their face is something that's going to be imprinted on my brain for a long time. And so while we all live for those moments when it goes well and we try to remember those, I think as physicians, we tend to focus on the ones that don't go so well. And really, those are the ones that stick with us. And in her situation, it was something I could never forget.
Tyler Johnson: [00:15:53] So we don't deal in the world of oncology with solid organ transplantation, right? That's not really our thing. But the thing that we have that is kind of close is bone marrow transplantation, right? And I'm not a bone marrow transplant doctor, but part of our fellowship has to do we do some rotations with the bone marrow transplant doctors and then certain kinds of cancer. That's a just a part of the equation, right? So bone marrow transplant medicine is a little bit complicated and in some ways it's a misnomer in the sense that an auto transplant is not really a transplant at all. Right? It's really just taking a person's own white cells and giving them back to them after very high dose chemotherapy. But an aloe transplant really is a transplant, right? You take somebody else's bone marrow. And in that case, it's strange because you actually destroy the bone marrow of the person who you're transplanting to and then give them someone else's bone marrow. Right. And I mentioned this only to say that I have sat through the discussion that the bone marrow transplant doctors have with patients before they go into a bone marrow transplant. And to the point that you're making it is such a strange thing because on the one hand, of course, they're only doing it because the person has an illness that will otherwise invariably take their life. Right. So they're already in this impossibly difficult situation that has usually left them very handicapped. But then when they have the discussion about the transplant itself, they have to say things like, you know, there is a 20% chance that the transplant itself or one of its, you know, ensuing complications will take your life.
Tyler Johnson: [00:17:33] But if you don't have the transplant, we know that your leukemia or whatever it is, is invariably going to take your life eventually. Right. And so then in that case, people enter into the hospital often for 30, 45, sometimes 60 or more days in a row to get the transplant, knowing that there's a 1 in 5 or whatever it is, chance that they'll never come out again. And some other I don't know the numbers, but some other high chance that they will come out but have serious long lasting side effects. Right. Some of which are are permanent. So I guess all of that is by way of framing this question, which is just to say, I know that you're not the transplant surgeon per se, but still, as the person who's kind of shepherding the patients, getting them ready for the process. How did you think about that dimension of being a doctor, that dimension of taking people into a procedure that even though you were going to do everything you could to make sure it didn't turn out this way, you knew could turn out like that horrific situation that you just described. Like how? I don't know, morally or ethically or psychologically. How did you cope with being involved over and over and over and over again in that kind of a harrowing experience?
David Weill: [00:18:51] Well, it was probably the most difficult thing that I had to do, because on the one hand, I think we have an obligation to tell patients the truth, tell them all of what we know about the risks, especially as it relates to something like transplantation. But on the other hand, I think we also have to give them hope. We have to give them hope that they're going to first be able to get an organ, that they're going to survive the waiting list, period. And then secondly, they're going to be able to survive after the operation. Sometimes I didn't get that balance just right. In other words, I was overly optimistic and I portrayed that to the families. And then there were other times when and it was usually colored by recent experience. If we had had a death in our program where I, you know, was sure to tell them that that could happen because it was so fresh in my mind. So I think one of the difficulties and every physician that I've seen in the transplant world does it a little bit differently, but I try to give them cold, hard statistics. And just as you suggest, recognizing that a lot of those statistics are derived by all comers, you know, in other words, they don't take into account comorbidities, age, disease, all kinds of different factors.
David Weill: [00:20:13] I think what's interesting about bone marrow transplant and especially lung transplant is patients tend not to hear that very well because they know whatever risk I describe, it's a lot better than what they're facing. And so we did not have to talk patients into getting our transplant. And as a matter of fact, they would come and meet us and very much wanted to get on the transplant list. But I recognize that at the same time, you've really got to be sure that they go in with eyes wide open and that, as your question suggests, that's a very difficult tightrope to walk. And for me, it was important that I understood that I was telling them all of what I knew because I didn't want it to go badly. And the family then, you know, say, Well, why didn't you tell me that beforehand and have that kind of expectation not met? So a tough part of our field, I think.
Tyler Johnson: [00:21:20] Yeah. You know, hearing you talk about that reminds me of two patients that illustrate for me a principle that you mentioned. One is that. Early in my time as an attending oncologist, there was a woman who had metastatic pancreas cancer who we were taking care of, and we gave her a totally standard chemotherapy medicine. It's one of the most common in the world. It's given, you know, multiple times every day in our cancer center and in general is, I would say, probably the gentlest chemotherapy medicine that I use. But she had this near catastrophic and ultra rare kidney complication from that chemotherapy. And she was one of the first patients that I treated with that particular drug. And so now every time I think of that drug, I think of this complication that happens in like 1 in 1,000,000 people who get the drug right. And so the likelihood is that I will never have another patient who has that complication. But I can't think of that medicine without that complication. And it feels like it's incumbent on me to tell all of my patients about that complication, even though it's overwhelmingly likely that I'll never see it again. Right. And then by the same token, I had a patient recently who got one of the other medications that actually arguably the probably one of the top three or top five most common chemotherapy medications in the world. It's given all the time for things like colon cancer and stomach cancer and pancreas cancer. And again, usually one of the best tolerated of all the chemotherapy medicines.
Tyler Johnson: [00:22:47] But there's a very small percentage of the population who lack a functionality in a particular enzyme that is supposed to metabolize the chemotherapy drug. And various tests have been tried to test for this enzymatic deficiency, but none of the tests really works very well, so we don't generally screen for it. And I had gone probably six and a half years into my career before having anybody with this enzymatic defect, but then I had a patient who did. And this medicine that is normally not a big deal and that people, you know, take with a little bit of a rash or whatever, but otherwise it doesn't bother them. Caused absolutely harrowing complications that led to this, you know, humongously long hospitalization and on and on and on. No one did anything wrong. It was not avoidable. You know, it's just part of what happens when you give this medication. But again, after seeing that patient experience, that thing, then every time I talk to somebody about getting that particular medication, it it just it hits differently. It feels differently, right? Like, you can't experience that as a doctor vicariously with your patient and not have it change the way that you think about it and not have you wonder how you're supposed to talk about that thing that it's again, overwhelmingly likely is not going to happen to the next 100 patients that you take care of, but you never know where the one is that it might happen to.
David Weill: [00:24:13] Yeah, I think that's right. And I think that to your point, as long as human beings are practicing medicine, we're always going to be influenced by, you know, what has happened to us, particularly those things that have happened recently. And we see this in the transplant arena. I kind of coach programs right now in a consulting role, and I see them all very much influenced by what happened last week. And that's going to happen until and therefore replaced by artificial intelligence, frankly. And I hope that doesn't happen because I do think it works both ways. We should not be overly influenced by the rare complications that we see in patients like you said suggested. But at the same time, there's there's something really wonderful, especially as you go through your career, of being able to pull from your own database instances where your clinical experience really made a difference and something that you saw or you remembered in the deepest recesses of your brain actually can positively impact a patient. So I hope we don't lose that. I think I think that's really important.
Henry Bair: [00:25:24] I'd like to shift somewhat and talk about something else, which is the actual process by which these lungs end up in a patient starting from, you know, where do they come from? I'm hoping you can tell us a little bit about that entire process, like who decides which patients get the lung? Because obviously there's you know, there's always a demand. Right. You know, is it is it challenging to match that demand and that supply? And if so, what are the challenges?
David Weill: [00:25:53] Yeah, I think the steps are pretty easy to say and a little harder to do. First, you have to get referred to a transplant program and have a disease that's amenable to transplant. The transplant program has to fully evaluate you from head to toe and decide if you're a good candidate. If they do, and your insurance company agrees, which is obviously problematic in our country, then you end up on a waiting list. You have to survive the wait. Then there's the operation, which, relatively speaking, is a smaller but very important part of our of our whole transplant process. Then there's the post-operative recovery period. And then you go on to hopefully live a long time and you get into a more chronic phase of recovery. But the organ donation process is something that's interests me throughout my career. It has not evolved markedly until very recently. In any meaningful way. We essentially had brain dead donors. A patient was declared brain dead at a site. The organ procurement organizations get involved and then they essentially shop the organ, if you will. And I don't mean that in a pejorative way, but they figure out after running through a computer match, who is up for that organ? And here's here's the hard part. Transplant programs have to be ready to go 24 over seven 365.
David Weill: [00:27:24] And they're really now managing that process all of the time, the organ donation process. Logistically, that's a bit of a nightmare. And that's where I spent most of my career trying to streamline that, trying to make it easier for us to get organs so that we weren't having to constantly fly out in the middle of the night, you know, to Idaho or wherever to pick up organs. And there are companies now involved in making that process more streamlined. There's devices that keep organs alive, and then there's systems now and infrastructure being put in so that the transplant centers can actually stay home, which is good for their rest and their burnout. And the organs will come to them. In an effort of also full disclosure, I serve on one of the boards of one of these companies called Transmedics. That's in this space. But I think. That's where the field is moving. We've got to make it easier for transplants to happen because too many organs right now get turned down for transplants just because the transplant programs can't logistically pull it off. And that's a shame, because right now, 105 patients listed for a lung transplant will die waiting. And I'd like to see that number move to zero. And I think we're headed that way.
Henry Bair: [00:28:52] So there are lungs that are not used because they can't either survive that process of transfer or they just they don't get to the patients in time. Is that correct?
David Weill: [00:29:02] Both both happen every night. And one of the things that used to really irritate me during the course of my career was when usable organs didn't get used either by our program or another program. That's extremely frustrating because the data suggests that the longer a patient stays on the waiting list and the more organs go by the wayside, that patient is at higher risk of dying in a linear fashion related to the duration of their waiting time. So I always knew that if we let an organ go, either for logistical or other reasons, we just expose that patient to more risk.
Henry Bair: [00:29:48] So there is obviously there's a there's a wait list, as you mentioned. How is the order of that list determined?
David Weill: [00:29:55] When I got into the field, it was first come, first serve largely. And I'm speaking now not only about lung transplant, but about all the solid organs. As time has gone on, there's a medical urgency based system. In other words, the sickest patients go to the top of the waiting list. And that's true whether or not you're talking about liver transplant, heart transplant or lung transplant. As it should be. But the downside of that is something that you can probably imagine, is that as we've gone to a more urgency based system, the candidates are sicker by definition, and therefore there's more risk to the procedure. And so while we're trying to improve the outcomes by doing the operation better, by doing the post-operative care better, we also, on the other hand, have a sicker group of patients that we're sending to transplant every night. That's the struggle that we're trying to to address. Let's not send somebody to the operation that's too sick to do well, but let's send somebody that's sick enough to actually be able to get an organ that night because of their their score on the waiting list.
Henry Bair: [00:31:09] So who who decides that score? Is it the transplant program like like the one that you were supervising?
David Weill: [00:31:16] Yeah. We don't decided so much as we input data and a score gets spit out on the other side. So in lung transplant, there's something called the lung allocation score or the Las and you input clinical parameters and the score gets punched out of a computer, basically. And that score can change as the patient changes. In other words, if the patient gets sicker, that score can be adjusted by the new input of data to update that patient's clinical situation.
Henry Bair: [00:31:49] One of the trickiest things when I when I personally think about this issue is, you know, as a as a clinician, especially since as someone who is supervising a program where you have a lot of these patients coming in. For you. It is a matter of you have limited resources. So you have to. Deploy them in a way that helps most people in the most meaningful way. But from the patient's perspective, obviously, it's like they just have that one life, right? And. You know, I'm wondering, what are those conversations like when. You have to tell a patient that maybe their number, their priority isn't high enough. I imagine that must be a really challenging conversation to have to lead and manage. Can you tell us more about that?
David Weill: [00:32:37] Yeah, and I write about this in my book as well, where it's usually patients that have gotten too sick and we can't find them in Oregon in time. And so it's a very difficult conversation, as you can imagine, to have a patient in the ICU there waiting for a transplant. We're talking to the patient, we're talking to the family, and then their disease progresses sometimes to the point that they need to be put on a mechanical ventilator and heavily sedated. And now we're just talking to the family. And we reach a point at times where we we run out of time. We we can't find an organ in time. And in fact, even if we found one, the patient's too sick to be able to survive the operation. And we have to go talk to the families and tell them that. Very difficult conversation, because I think, Henry, as your question suggested, the patients don't really care about whether or not a patient is too sick. They just want to have their loved one survive. So they're just like, why don't you just go ahead and do it? There's a lot of reasons that we don't take these kind of big chances in transplant where somebody has a 10% chance of survival.
David Weill: [00:33:52] One is we know that the resource is precious. There's not enough lungs to go around. And we we don't want to put them in people that don't have the opportunity to do well after transplant. But to something that's less talked about is the program has to worry about its own survival statistics. We live in a highly regulated world in transplantation and. If programs were being fully transparent, they would say that yeah, there are times when they make decisions based not only on what's good for the patient, but what's also best for their individual transplant program. Because if they were to transplant patient after patient after patient that had little chance of survival after transplant, they wouldn't be doing it very long. And, you know, obviously people in our field want to continue to be able to do transplantation and offer it to their patients. But if they don't, if they're not good stewards of their own program and the their donor pool that's available to them, they won't be doing it very long. And that's the kind of work I do right now in helping programs calibrate that risk properly.
Tyler Johnson: [00:35:05] But I think you can imagine, right, that for a patient and their family members, these waters can be so enormously difficult to navigate. Right. Because on the one hand, in the case of lung disease in particular. Right. I think it's hard for someone who and again, I'm not a specialist in this, but I've taken care of these patients over the years in various capacities. Like it's hard to understand what life is like for somebody with progressive interstitial lung disease unless you've seen someone who has interstitial lung disease. Right? It's like it's sort of like filling your lungs slowly with Velcro over years. Right. And it just gets worse and worse and worse to the till. People get to the point where they are literally bed bound because their lungs just won't supply enough oxygen for them to even move across the room. So on the one hand, you have this person who's getting sicker and sicker and sicker, and the doctors are saying, well, they're not quite sick enough yet. They're not quite sick enough yet. They're not quite sick enough yet. And then I know that it sometimes can feel for the families. Like then there's sort of this paper thin margin between not sick enough yet and neither too sick. Right. Or some complication happens and now they've gone from not sick enough to too sick. And then by the same token in for liver transplant patients who I cared for a lot more in my residency that time around, the actual transplant, both before and after, is just so it's harrowing, right? Because I mean, literally by the time the liver is failing and they're getting ready for a liver transplant, it's like their physiology is just unspooling.
Tyler Johnson: [00:36:39] Right? They can't process glucose. They can't keep their blood pressure up. They can't fight against infections. Their bone marrow is all off. I mean, everything is going wrong. Right. So you're sort of I mean, it feels like as the doctor, it feels like you're trying to balance nine spinning plates in the air just to keep them alive until the liver can get there. And then once the liver goes in, as you mentioned, now there's a whole bunch of post-operative stuff and you have to worry about the, you know, whether the organ is taking and is there any sign of rejection Now you're putting them on immunosuppressive medications when they just had a major operation. And I mean, it's just it really is. Um, you know, it's sort of this super distilled form of many of the most intensive kinds of medical care that we provide for patients, both medical and surgical. It's staggering that it ever works at all on the one hand. And then it's but then it is also just I mean, it's exhausting just to talk through the process for five minutes, let alone to be the patient or the family member who's actually there living it.
David Weill: [00:37:38] Right. Tyler, as you were going through that, I reminded myself why I'm consulting now rather than in the front lines of this. You know, it's very difficult. Look, it's all of the intensity of medicine compressed on steroids, whatever cliche you want to use, no pun intended. No pun intended. And it's difficult. I, I know for sure that it's difficult for patients. My father actually received a liver transplant early in my career, so I got it from the family member's side as well. And I. I know how difficult it is, but I'm also reminded how difficult it is for the people trying to provide this kind of care. And I don't want to compare what I went through or what my colleagues in transplant went through to the person getting the new organ. I would never equalize those things. They're not equal. But I would say that living on, you know, that razor's edge all of the time does take its toll. It did for me, and I think it does for a lot of people in my field.
Tyler Johnson: [00:38:46] So can we actually as long as you're bringing that up, one thing that people may have picked up on from a couple of comments that you've made is that for all that we're talking about and all of the many years and very, very hard work that you put in to becoming a transplant doctor, you are now not actively practicing as a transplant doctor. So how did that come about? How was it that you ended up leaving, in a way, the direct or face to face medical field?
David Weill: [00:39:17] Yeah. I decided in 2016 that I would step away from the front lines. I even thought early in my career I became a transplant doctor when I was in my early 30s, and I thought even then, I don't know why I thought this necessarily, but I thought even then that I would probably have about a 20 year career in it. And I thought that I would probably need to do something differently. I saw early on the toll that it was going to take on me, and I saw what was going on with some of my colleagues. So a lot of different factors came to a head in 2016, and I had reached a point where I didn't have the same kind of emotional health that I wanted. I didn't feel like I was devoting enough time to my family. I don't even think that I was actually in a position to maximally help the patient group that I was taking care of because my life really wasn't in the kind of balance that I wanted it. So I decided to step away from Stanford, very good position at Stanford and take a different tact. And so I knew that I had learned some things along the way about transplantation and wanted to figure out a way that I could stay involved in the field.
David Weill: [00:40:34] And rather than be in the quarterback, I could be the coach and try to help transplant programs perform better. And that's what I do now. And it's very gratifying. Frankly, I'm not I'm not here to say that I don't miss the one on one patient interaction. I do. And I think about it a lot. And my patients still contact me and talk to me. And I'm reminded of how important that was to me. But at the same time, I think I'm more broadly helping the field now. So instead of working at an individual program like Stanford, I get to impact programs from coast to coast that are going through the same struggles that I went through early in my career and help younger doctors not only. Perform their craft better. But I also talk to them quite a bit about how important it is for them to stay both physically and emotionally healthy while they're doing this. And we spend a lot of time talking about that.
Tyler Johnson: [00:41:31] So, you know, we have talked with many guests who come at this from all different angles. So we've talked with a number of doctors about this, sometimes a little bit, sometimes a lot, sometimes directly, sometimes indirectly. And we've also talked with people who are not directly medical professionals, but who are experts in burnout or experts in finding balance in life or living a rewarding life, whatever. All of which is to say that I think everybody recognizes that for most committed full time doctors, this is a challenge, right? This idea of keeping what you do in the hospital or at the clinic in balance with the other elements of your life is a challenge. And so I guess the question that I would ask. Is. If it's a challenge for everybody, if it's not too personal, if you don't mind sharing, what was it that kind of. Led you to recognize that the scales had tipped for you personally. That led you to say, okay, this has always been a challenge, but now we've gone from a challenge to a place where this has gotten so out of balance that I actually need to leave face to face medicine and do something else.
David Weill: [00:42:52] Yeah, it was a process for me. It wasn't really one thing, but it was a cumulative effect, as we like to say in medicine. I think the first bit of it was when I had two daughters and then I started looking at some of my patients like they were my children, and I was comparing fathers and mothers, parents of children that were going through transplant. To my own experience, how would I feel if one of my daughters had to get an operation like this? And so that was like a first crack in the armor. Then my father got transplanted. Then I went through ten, 12 years of recovery with him. Then he passed away. Then. My patience, I was focusing more and this was the straw that broke the camel's back. I think I was focusing more on the patients we lost rather than the patients that did well. When they did well, that was just holding serve, to use the tennis analogy. But when they didn't do well for me, that was a personal failure. And it was that shift in thinking that I believe ultimately led me to the decision 1st June morning to walk out and basically say that, you know, my time is up.
David Weill: [00:44:13] And so I think in retrospect. I might have wanted to recognize these steps along the way and tried to address them more fully. But like many of us in medicine, I was taught head down, work harder. If there's a problem, just work harder. And that turned out not to be the best recipe. But on the flip side, I feel gratified to be doing what I'm doing now. I'm lucky to be doing what I'm doing now because I had that intense hospital experience. But I also get to do something very different right now that I do think is gratifying. I think it's important, you know, to to the field. So in a lot of ways. You know, I've read a lot about burnout. I don't look at it as some kind of personal failing, but I do think it's the opportunity to turn a page and start a new chapter and go in a different direction. I don't think it has to be looked at as well. That was a failure. That was a bad outcome.
Tyler Johnson: [00:45:20] One thing to pick up on that. So on the one hand, I completely agree with you that what I do not want to do is I don't want to engage in what sounds like failure analysis. Right? I don't want to say, well, that all was for naught or something and let's figure out how that happened. And so it doesn't happen again. But what I do hear you saying is that even to the degree that you appreciate the job that you're doing now and that you're glad that you have a chance to contribute to the field in a different way. What I also hear you saying, correct me if I'm wrong, is that regardless of the value and validity and whatever of what you're doing now, as you look back on your career as a physician, what I hear you saying is that in retrospect, you see your life as having been out of balance and you see yourself. It's not like you sort of gracefully thought, Oh, I've got this great idea of a second career that I'm really inspired to go pursue, so I'm going to go do this other thing. It was more, you know, this weight after this weight. After this weight, after this weight. W e-i-g-h-t and then it all just got too heavy. And as you said, then there was a straw. The camel's back broke and you stepped back from medicine in effect, because you just it was it had become too much. And so all of that is just to say if you could go back and do it again. Regardless of whether you would have eventually come to this job or not, what concrete things would you have done differently so that you wouldn't have ended up with bearing this load that was just too heavy and became toxic and unmanageable?
David Weill: [00:46:58] Yeah, it's a thoughtful question and a good one because I do talk to a lot of folks about. The fact that I had a great career and I'm proud of it in the hospital, I didn't go out on a high note. You know, in other words, it was not the graceful, elegant off ramp that I had envisioned when I was younger. I mean, I kind of went limping away a little bit. I'm not too proud to admit that. But at the same time, if I had to do one thing differently. I would encourage people experiencing something similar to stay connected. And that doesn't mean. Connection to their patients. That's important. And I and I actually did that even all the way to the end. They were they were the group that I could really stay connected with because they cared about me. They said they cared about me. They knew something was up. I lost connection to my colleagues. I lost connection in certain ways to my wife and family. Lost a little bit of connection to my friends. Isolation here is the enemy. So if you're experiencing something like this, you've got to stay connected to all of the people that matter in your life. And I've written about this in op eds that I've written.
David Weill: [00:48:19] I mentioned it in my book. I also am a big believer in therapy. I think it's really important. I think we need to destigmatize it and being a middle aged man. Therapy was not something that I ever, ever thought that I would end up in, but. I found it very useful. Not because the therapist has an answer to your problems. They don't. They won't stop my patients from. From dying. What it does is it asks you to question your thoughts and to make you realize, and somebody like me needs to realize, hey, you're not in control of all of these patient outcomes, even the good ones, right? And they make you question how you're thinking about it. And that's why I found it so useful. So those were the steps that I think. Anyone should take. But I think the main message would be that just remember, if you're sticking your face in a book, when you get home at night or you're watching a game on TV and you're not talking to your family and you're not hanging out with your friends and you've got an isolated from your work colleagues, things aren't going well.
Tyler Johnson: [00:49:31] So I mentor a lot of students at Stanford, and one of the things that I am coming to conclude over time is the most important thing that I can teach them is the idea that, you know, in medicine in particular, I think because medicine is thought of as a noble profession, it's easy to almost anthropomorphize the field of medicine. Right? And it gets to the point where you almost feel like you can have a relationship with the field of medicine, which sounds like a strange thing to say, except that the implicit message that we end up telling ourselves is that the field or the institution, the medical school, the division, the department, whatever, that it will love us back. Right? That if we just pour love and passion and devotion, that it will love us back in the way that a friend or a significant other or a husband or wife or child or whatever would. And there are people who I really think pour their lives into what sort of vaguely feels like a relationship in the hopes that it will love them back. And it never does. Like I just last night I got an email from our division which we get from time to time about this year's promotions. Right? People who were assistant professor who are now associate and people who were associate and now professor and on the one hand phenomenal achievement. I'm so happy for them. I sent congratulatory emails to the people in the division who achieved it and whatever. On the other hand, every time I get one of those, I'm like. Really? This is like, do you know how many years and papers and hours and blood and sweat and tears got poured in to having the word assistant changed to associate? Mean it's like one of those things in Manhattan.
Tyler Johnson: [00:51:19] Like, I came all the way to Manhattan and all I got was this stupid t shirt. Like, forgive me, but it's like I worked for eight years and all I got was this email saying, Now you're the associate for like, what the heck? Like outside of medicine, not even knows what the dumb words mean, right? Like, it's. And so it's just to say and I'm not, you know, I mean, obviously I'm working just like everybody else is, and I want to get promoted just like everybody else does. But the point is just to say it will not love you back, right? Like it will not be there waiting for you to comfort you when you are sad and get home at night or whatever, right? Like it's just not the same. And so there is a way to keep that in perspective and, you know, do a good job at your job and yes, get promoted when it's your time and, you know, write your papers and whatever. But but it has to be kept in perspective. If it if it becomes the thing if it becomes if it displaces the most important relationships in your life, because you have come to sort of implicitly think of it as a relationship, as you state, it will leave you lonely, it will leave you disillusioned, It will leave you empty because it can't the institution can't love you back.
David Weill: [00:52:29] That's extremely insightful. And I agree, and I haven't heard it quite phrased that way, but I wholeheartedly agree. Me personally, yeah, I love my titles. Just like everybody in academic medicine loves their titles, but at the same time, the patient interaction was something that I was craving in a codependent, I think, kind of way. And, you know, in other words, I think all of us to a certain extent are gratitude junkies. And when patients tell you that you saved their life, that's the ultimate high. I was probably all the way on the right end of the spectrum of gratitude junkies. And when patients told me that I really believed them, you know, that I had actually saved their life and. I do think you're right, though, that regardless, you know, the people around you, family, friends, your faith, whatever you believe in is going to be the thing that sustains you forever and ever. But it's very difficult to tell a young academic physician at Stanford or somebody else that that's really the case, because I do think it's experiential. I think until you actually go through it, it's very difficult to see, or at least it was for me. But what I am encouraged by is that a lot of discussion about this very topic is going on, including your podcast and others that I think are going to inform the next generation of physicians much better than I than I was informed.
Tyler Johnson: [00:54:01] David, we have reached the the end of our time. But before we let you go, and you've already spoken this to this a little bit, but we still want to give you the chance to have your kind of your official parting shot. You know, one thing that is so interesting about your journey and that you've been that you've talked with us about very candidly is that, you know, not everything has gone exactly the way that you would have wanted it to go. Now, of course, the truth is that that's true for every person who's ever existed on the planet. But you're just talking about it, which not everybody does, right? So with that candor that equips you then to many of our listeners are trainees or young attendings or whatever. If you could go back 20 years and find the 20 year ago version of David Weil, who's there, you know, laboring away, you know, doing everything they can to to take care of their patients and to publish papers and whatever, do all of the things what what would you tell the 20 year ago version of you to help him be a wiser and more balanced person?
David Weill: [00:55:11] I think it would be two things, really. I think the first would be the idea that connections to your work colleagues, to your friends, to your family are going to be what, sustain you. And I wouldn't just say it. I would believe it because it's really, really true. I think isolation is the enemy, and I think that it has to be avoided in our field. The other thing I would say are about. I would give advice to myself 20, 25 years ago about my role in the universe. And I don't want to get too far out there, but there is the notion that many of us had that if we do our job well enough, if we work hard enough, we're going to be able to save every single patient, even in the field of lung transplantation, that we encounter. When you say that out loud, it actually sounds ridiculous. But many of us walked around with that notion for many, many years. And I know I did. And I would remind myself a younger version of myself that I'm not responsible for either or wholly responsible for either the good outcomes or the bad. And I would actually believe that as well. So those are the two main points I would make to myself.
Tyler Johnson: [00:56:32] Well, we appreciate so much all of the wisdom that you've shared. We especially appreciate your willingness to be candid in the service of helping those who are listening to to hopefully gain from your wisdom and have a little bit of your perspective a little bit earlier on. And I'm confident that that willingness to be candid will really help people. So we we really appreciate your insights.
Henry Bair: [00:56:55] Yeah. Thank you so much, David.
David Weill: [00:56:56] Yeah. And thank you for having me and I really appreciate what you guys are doing. I think it's important.
Henry Bair: [00:57:03] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:57:22] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:57:36] I'm Henry Bair.
Tyler Johnson: [00:57:37] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.