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Join David Weill, a pulmonary and transplant physician and author of Exhale: Hope, Healing, and a Life in Transplant. In this episode, we explore the emotional and ethical challenges faced by David during his career, where every patient became family. Discover the world of organ transplantation and gain insights into the complexities of health care and the quest for hope and healing in extraordinary circumstances.

David Weill is a pulmonary and transplant physician.

He discusses the book, Exhale: Hope, Healing, and a Life in Transplant.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome David Weill. He’s a pulmonary and transplant physician and the author of the book Exhale: Hope, Healing, and a Life in Transplant. There’s an excerpt from that book on KevinMD. David, welcome back to the show.

David Weill: Thank you, Kevin. Thanks for having me again.

Kevin Pho: We were just talking offline; you were on several years ago. For those who didn’t listen to our first episode together, just briefly share your story and journey.

David Weill: The book is about my life as a transplant physician. I headed the lung transplant program at Stanford for most of my career, and it’s about the emotional roller coaster, the ups and downs of doing that kind of work. There are a lot of patient stories, to be sure, but there are also a lot of stories about what the team goes through when it’s trying to deliver this kind of care.

Kevin Pho: Perfect. So in this particular excerpt, you talked about a night in the ICU, and that gives us a real window into what your life is like. Share the story.

David Weill: In the book, I wanted to go through the very real-life drama of what happens when we transplant somebody. Sometimes it works really well, sometimes it doesn’t work so well, and sometimes there are people on the waiting list who die. I wanted to be sure I told all those kinds of stories. The excerpt you have is about somebody who needed a second lung transplant, was on the waiting list and just didn’t make it in time. The conversations I would have around those situations were really difficult, as you might imagine: trying to explain all this to the family, given how invested we were as a team and, of course, how invested the family members were in seeing a good outcome. That’s just an example of the kinds of stories I tell.

Kevin Pho: What makes transplant surgery different from other surgical subspecialties?

David Weill: I think there are a lot of differences. The mystique of it is certainly there, and the magic of it is there. With one operation, you can essentially take somebody from death’s doorstep and turn their life around. We used to say at Stanford that it was the ultimate reset button. But it’s a high-risk game, and what maybe folks don’t know about is how often things go wrong. There are moving parts to it, and it’s a human endeavor. I was one of the humans doing it: not perfect, sometimes doing a great job, sometimes not so good.

What I also wanted the reader to know, and I’ve had patients respond to this part of the book, is that doctors aren’t robots. We’re not out there just treating people, and if it works out, great, and if it doesn’t work out, that’s OK too. We’re actually human beings who a lot of times get very close to the patients we take care of, and I think that was especially true in transplantation. In a lot of medical subspecialties you have a lot of patients. We had a lot of patients, but not so many that I couldn’t know their family members, their dog’s name, their kids’ names and so on. One of the things that drew me to the field was how close you get with the family members.

Kevin Pho: So take us through the process of transplant. How long would you know this patient? How many times would you see this patient? Take us through the general process of a patient going on a transplant list, from beginning to end, just to give us an idea of the scope and of how many times you see this patient and really get to know them.

David Weill: When I was at Stanford, we would evaluate about 300 patients a year for a lung transplant, and we would invite about half of those to actually come see us. So a lot of what I did as leader of the program was evaluate medical records and decide whether it was a good idea for the patient to go through the workup. It’s a three-day, very intensive, head-to-toe workup, and I didn’t want to put anybody through that unless they had a realistic chance of getting a transplant. So a lot of what I did was select candidates for the waiting list. After the three-day evaluation, which again is head to toe, we don’t leave any stone unturned, and there’s a psychosocial component to it as well, just to make sure the patient is up to getting this kind of care, we would bring all that information to a meeting of the entire team. Sometimes we agreed on candidates, and sometimes we didn’t, and I show in the book what those discussions look like behind closed doors.

Kevin Pho: So give us a little taste of some of those discussions. What’s it like determining some of those ethical considerations about who receives a transplant and who doesn’t? Because it sounds like even the committee often doesn’t agree.

David Weill: We disagreed less on medical aspects, although sometimes a 70-year-old would come to see us, and folks would wonder what kind of 70-year-old it was, because 70 years old is a very relative term. So sometimes we disagreed on medical aspects, but other times we disagreed on what kind of patient, quote unquote, they were. Had they used drugs in the past? Were they compliant with their medical regimen? Were they likable? In fact, I’m afraid that some of those more subjective measures often came into the selection process, as much as we tried to keep them out.

Kevin Pho: Could you give us an example of one of these borderline, gray-area situations? It could be hypothetical, or it could be an amalgamation of your experience, but I’m interested in hearing an example of someone who was in that gray area, where it could have gone either way.

David Weill: Some of the gray areas we dealt with involved people who had committed a crime in the past and served time in prison, or maybe weren’t as compliant with their medical regimen, or had abused substances, and we had to make judgments about whether they deserved a second chance. Sometimes that’s very difficult to determine. We don’t really know, and sometimes we were wrong about whether a patient had reformed their life. You got very strong opinions in the room. Some people would say, for instance, that if you served jail time and committed a felony, you should never get a transplant, or that if you were an undocumented person in our country, you should never get a transplant. Having practiced mostly in California, we had some people from Mexico who had come across the border seeking a lifesaving procedure, and whether that person should get a transplant in our health care system was a question we grappled with fairly regularly.

Kevin Pho: Now, are there any guidelines that help with your decision-making? If you had a gray-area case go before your committee and then put it before another committee at another hospital, is it conceivable that you’d get two different outcomes?

David Weill: You do, and that’s a really good question. In fact, I wrote one of the recipient selection guidelines for our international society back in 2015, but there are gray areas where the guidelines really don’t dictate one path or the other. Whenever we turned down a patient for transplant, we would always encourage them to go to a second center. We didn’t have the corner on good judgment, the corner on that market, so we would always say, “Look, we can’t do the transplant here, but if you want to go to San Francisco, Los Angeles, Denver, Seattle, wherever, then you should do that to get another opinion.”

Kevin Pho: How is the decision ultimately made?

David Weill: It very rarely came down to a show of hands, but occasionally it would, and we’d actually vote on it. Most of the time we could make a decision without having to go to that step, but sometimes we actually had to vote, and a lot of times it was quite a close vote.

Kevin Pho: Give us a sense of how big this committee was and whom it comprised.

David Weill: It was a multidisciplinary team of physicians, surgeons, nurses, nurse practitioners, dietitians, nutritionists, social workers, who are very important to the team, and psychiatrists, and everyone had a vote. Everyone had a say. As with any large group, some people were more influential than others, but when we would sit down to meet, there were 40 or 50 people in the room.

Kevin Pho: Oh, and how long would these deliberations take for a typical gray-area case?

David Weill: Sometimes up to an hour. A lot of times, when a very straightforward transplant recipient came forward, we would decide in 15 seconds, and other times it took a full hour.

Kevin Pho: What would you say is the most challenging part of your job?

David Weill: I think by far it’s the patients we lose on the waiting list. I don’t tolerate well the patients who die after the transplant; that’s hard. But the patients who died on the waiting list, who never got an opportunity to be transplanted, were especially hard on me and the rest of the team.

Kevin Pho: And where do you go for support? This isn’t something you’ve necessarily been trained for in residency, and these decisions are obviously life-altering for these patients. Do you have a place where you can talk and debrief once these decisions are made?

David Weill: We really did not have that when I was at Stanford, which was too bad. I think COVID has actually brought to light the fact that we do need to talk to one another about what we’re experiencing, so I think the situation is better now. I, for instance, would go to the gym, try to work out as hard as I could, ride my bike, do something to get my mind off it. But I think it probably would have been better if we had been able to talk to each other in a safe, open way.

Kevin Pho: So tell us about the state of transplant surgery today. What are some of the challenges facing the field?

David Weill: I think it’s really exciting, what’s going on right now, and a lot of the excitement is about how we allocate organs in this country. In full disclosure, I serve on the board of a company called TransMedics, where we can actually move organs around the country and keep them alive, taking away some of the logistical challenge for a transplant program, which has to be ready 24/7, 365, and delivering the organ right to the hospital’s doorstep. So I think the biggest revolution I see out there right now is keeping the transplant team in bed and at home as long as possible and making the organ allocation process less cumbersome and less work-intensive for the transplant program. I think that’s been a huge step.

Kevin Pho: Now, for the medical students who may be listening to you, what kinds of characteristics or qualities should they have if they were to consider a career in transplant surgery?

David Weill: Commitment. I think commitment is absolutely required for our field.

Kevin Pho: And what do you mean by that? I’m sure many surgical subspecialties require commitment, so talk about it specifically.

David Weill: Because the cases are not scheduled; they can happen anytime. I think there’s really no off time per se. There are times when we may not be directly in the line of fire, but you have to understand that, because transplant organs become available when they become available and they’re a precious resource, you have to be ready to go pretty much all the time. That may sound awful to some of your listeners, but at the same time, the reward is tremendous. I can’t think of another field where you get to see the impact of your work as dramatically as you see it in this field.

Kevin Pho: Can you share with us one of your most rewarding cases?

David Weill: I always look back to the cystic fibrosis patients we transplanted. I even go back to the first patient I ever took care of after training. We transplanted an 18-year-old who had cystic fibrosis and had never gotten a chance to breathe without oxygen, and he was able to run a five-kilometer race just six months after his transplant. I ran it with him. I won’t tell you who ran faster that day, but it was amazing. You take somebody who essentially didn’t have a childhood, and with this one operation, we can turn things around.

Kevin Pho: So what are some of the other main messages you want readers to come away with after reading your book?

David Weill: In the book I talk a lot about the fact that, yes, transplant is a demanding field. Yes, we perform miracles, but things can go wrong, and we have to try to be able to accept both. I also try to be more open about taking care of yourself in this field. Even before COVID, I think transplant doctors had pretty short careers, at least clinically; they went on to do other things, and some of my mentors did that. But one of the messages of the book is: Look, you can do this field. You can take care of patients, and you can take care of yourself. Trying to follow that example is critical to what we do, because we don’t have enough transplant physicians and surgeons to go around right now.

Kevin Pho: We’re talking to David Weill. He’s a pulmonary and transplant physician and the author of the book Exhale: Hope, Healing, and a Life in Transplant. David, tell us some of the take-home messages that you want to leave with the KevinMD audience.

David Weill: I think for all the students, the early residents and even the early practitioners, the fully trained practitioners: Talk to each other. Stay connected to one another. The people who understand best what you’re going through are the people you work with. When I made mistakes in my field and in taking care of myself, it was when I became more isolated from my work colleagues. Don’t do that. I am optimistic, though, that this generation of physicians is doing that a lot better than we did.

Kevin Pho: David, thank you so much for sharing your story, time, and insight, and thanks again for coming on the show.

David Weill: Thank you, Kevin. Appreciate it.