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In View: People in Transplantation

Robert A Montgomery, MD, DPhil Pioneering Surgeon and Transplant Recipient, NYU Langone Transplant Institute, NYU Langone Health, New York, NY

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doi: 10.1097/TP.0000000000002964
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During your early days at a Catholic school, nuns commented that “Bobby thinks that rules do not apply to him.” That motto seems to have had an impact on career and life.

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RAM: The nuns and I did not get on well. Yes, it is true; my second-grade teacher wrote those words on my report card. Though her words were intended to be derogatory, she had identified the characteristic what would become my greatest gift. My mother pulled me out of the Catholic school system and put me in a public school. My grades improved and so did my ability to cope with the classroom. What remained throughout my life was a fundamental rejection of dogma or projected limitations. My thinking is just naturally disruptive and while this has not always served me well, my irreverence of convention and established thought has been the fuel that powered whatever new things I have brought to our field.

You have spent longer periods of time in Africa before medical school exploring the interface between Western Medicine and traditional healing. Has that experience modified your view on currently practiced Western Medicine?

RAM: My time wandering in Africa was another defining period in my life. The lessons were many. I lived with and observed traditional healers in tiny villages throughout Africa in the early 1980s. I watched them connect with their patients and bring them back to health in the absence of everything we believe to be essential to legitimate patient care. That changed the way I practiced surgery. The manner in which they connected with their patients remains with me until now. When I go into a patient’s room, I sit down on the edge of the bed. I take their pulse, touch their hand, and reassure them that things are going as planned. We have a conversation. I am looking at them, not the door.

You had been diagnosed with heart disease during surgical residency. What were the responses by your program Director/Department chair? Did you consider a change of career?

RAM: During my second year of residency at Hopkins, I was diagnosed with familial cardiomyopathy. I was 29 years old, and one of my brothers had just had a sudden death. My doctors stressed me on a treadmill, and I had runs of ventricular tachycardia. They implanted one of the earliest models of an implantable cardioverter-defibrillator (ICD) in my abdomen, which had only recently been invented at Hopkins. It was a large, uncomfortable device prone to misfiring. I was the first practicing surgeon in the world to get an ICD. They were not even sure I would be able to use an electrocautery without getting shocked. Dr John Cameron, the Chair of Surgery at the time, stood behind me. To this day, I do not know why. He asked me what I wanted to do, and I said I want to be a surgeon. There were only 4 categorical surgery spots and any number of talented people who could have taken my place. He told me to go to the lab and let us see what happens. When I returned to Hopkins 3 years later, I went to the electrophysiology lab and used the cautery while being monitored and was cleared to rejoin my residency.

During your lab years, you went to Oxford to study with Sir Peter Morris and Dr. Maggie Dallman as a Fulbright Scholar. How did this experience shape your career?

RAM: Oxford was a nexus of transplantation biology research training at the time. Talented young doctors came there from all over the world. They were perhaps the most intellectually stimulating years of my life. My mentors were very disciplined scientists and taught me to be the same.

You went on with a most successful career in academic transplant surgery with many pioneering achievements. You have contributed with ground-breaking work in desensitization. What do you consider your greatest achievements in this area?

RAM: I was not married to any single approach. I discovered this underclass of sensitized patients that were being warehoused on transplant lists throughout the country in the late 1990s. Their plight resonated with me. I dedicated my career to finding options for them. Desensitization was just one solution. They came from everywhere, and for 15 years, our wards were filled with patients disenfranchised from access to transplantation, seeking hope. Everything we were doing was new. We performed the first chains of transplants for incompatible pairs initiated by altruistic (nondirected) donors. We tested new drugs and protocols for desensitization, used algorithmic approaches to combining paired donation and desensitization, employed complement inhibitors for the treatment of antibody mediated rejection, antiphospholipid antibody syndrome and atypical hemolytic uremic syndrome, and took on patients who had no apparent vascular sites to land a kidney and no vascular access. We jokingly referred to ourselves as the Supreme Court for kidney transplantation at the time.

Where do you see the future potential of paired kidney exchanges?

RAM: The National Kidney Registry took the concept of paired donor chains, scaled it, made it accessible, and improved upon it. Where I see this going is the complete uncoupling of live donors with their intended recipients. Innovations in HLA-epitope matching, genome sequencing, managing big data, donor vouchers, and artificial intelligence/machine learning will drive the field towards precision pairing of donors and recipients. We will have a list of donors and a list of recipients, and the computer will create matches that will be weighted for best long-term outcomes, lowest rates of rejection and de novo antibody formation, safe immunosuppression minimization, and lowest cost.

You have also been a most successful mentor and some of the most prolific surgeons having been your mentees. What is your “secret” of mentoring?

RAM: I consider preparing the next generation of doctors the most important thing that I do. There is no secret. You have to set an example of excellence and compassionate care, invest time and interest in trainees, and create an environment that inspires young physicians and surgeons. They need to want to be there and know it is a special place.

You became severely ill by the end of 2018 but have been aware about your heart condition for many years.

RAM: Yes, I suffered a series of setbacks starting in June of 2017. I collapsed in Patagonia and spent 3 weeks in a tiny hospital on a respirator and a levophed drip with pseudomonas sepsis. I had cardiogenic shock with an ejection fraction of 10% and was too unstable to move. It was a miracle, but I recovered and returned to performing transplants, but things fell apart again a year later when I was in Italy at a living donor meeting. I developed ventricular tachycardia storm and had multiple cardiac arrests. With the help of a friend, I checked myself out of the small hospital in Matera and flew back to NY and got admitted to the Intensive Care Unit to wait for a heart.

You have not only been a pioneering surgeon but also a pioneering patient. After being listed for only 2 weeks, you had been transplanted with a heart from a Hepatitis C positive, increased risk donor. Has there been any hesitation in accepting this heart?

RAM: I was very aware, even in the direst moments, that I was a leader and needed to set an example. I felt I was still alive for a reason, and that reason had just changed. Now I had to bring to bear the same perseverance, resilience, and unconventional thinking that guided my professional life to being a patient. It was an easy decision. I have been a champion of using increased infectious risk donors since the 1990s, and we initiated the first Hepatitis C+ to Hepatitis C− trial at Hopkins just before I left for New York University. I have been discussing this idea with Dr. Niraj Desai, who did that first transplant, for years.

You have continued your surgical academic career transition-free after your heart transplant. What were your challenges in returning?

RAM: I was working immediately from my hospital bed during recovery. Work helps me, which I think is true for most people. I have spent this past year concentrating on my leadership activities and research. I started seeing patients in clinic 2 months after the transplant, but a tacrolimus-associated tremor prevented me from operating. I had to wait at least 8 months until it was safer to attempt a tacrolimus-free regimen which I recently transitioned to. This was an extremely difficult decision because I was otherwise doing well, but my work as a surgeon was important enough to me to take this risk. The tremor is gone, and I am back in the operating room and doing all aspects of my job. It turns out that <20% of our patients return to full-time work after a transplant. I think this is failure in our mission and I am devoting time now to instigating this.

Without any doubt, your life is busy. What do you do to recharge? What are things that you like to do outside of the hospital?

RAM: I am an outdoorsman. I love to hike, photograph, hunt, and fish in remote, beautiful places throughout the world. It is a great pleasure of mine. Since my transplant, I have really enjoyed aerobic exercise, which I was cautioned against doing for the last 30 years. I have a 25-year-old heart and joints that have not been overused, an amazing combination for someone my age. Basically, I am rocking on with some brand new components!

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