CHAPTER 14
The Contours of Change
Dr. Pomahac and the Challenge of Influencing Multiple Senior Managers and Surgeons to Allow the First Facial Transplant in the United States
Background: The Need
It would be very difficult to find a more challenging influence project than the one undertaken by Dr. Bohdan Pomahac of Boston’s Brigham and Women’s Hospital. A young plastic surgeon, he had been treating a patient whose face had been so badly burned and disfigured that he wouldn’t even leave the house. The Doctor knew that no matter how much reconstructive surgery he did, the net effect would never be acceptable.
Dr. Pomahac had been following the articles and discussions about the possibility of facial transplants. When a French team actually did the first one in November 2005, he resolved to find a way to do it himself. He knew that they not only replace what is missing for the patient; they can truly transform lives. The challenge would be to overcome the resistance of his own department, senior surgeons, large teams of doctors and nurses, and the regional organ donor agency that would have to find families willing to donate a deceased family member’s face. He’d also have to persuade elite surgeons to let him take the face first (endangering the removal of organs they were waiting for), and then raise millions of dollars to pay for not only the surgery but the lifelong course of immunosuppression drugs that would be needed. Each step could be a major influence hurdle in its own right; taken together, they seemed insurmountable. He spent more than three years gaining acceptance and support.
We first learned about Dr. Pomahac from a splendid feature article in the Boston Globe1 that outlined many of the individuals and groups he had to influence. He graciously agreed to fill us in on his thinking and methods.
Dr. Pomahac’s story is so important because he combines an intuitive feel for what matters to people whose cooperation he needs with an analytical ability to think through the steps required to achieve his goals. The senior surgeons he approached at his teaching hospital advised him to follow the traditional route: lay out a laboratory research plan and do the investigations and publishing that would prove the methods and value of facial transplants. Because Dr. Pomahac knew that process would take about 10 years, and patients were suffering deep social isolation, he thought about the possibility of reverse engineering: doing a facial transplant or two and using that as the start of the backup research in his lab and possibly elsewhere. This was an option because there were no new and unproven technologies involved; it wouldn’t require Food and Drug Administration approval. Though facial transplants were incredibly complex, the microsurgery, technology, and immunosuppression were already well established with other kinds of transplants. No one had put it all together.
Until the French announcement, facial transplants were a “hobby project” for Dr. Pomahac. His main efforts as an attending physician were to set up a laboratory and a series of experiments in cartilage engineering. That was proving to be extraordinarily difficult, with crazy hours and “slow, pathetic progress.” So he set out to find another senior surgeon who might support him.
Finding Allies
He soon discovered two interested senior surgeons: Dr. Elof Eriksson, chief of plastic surgery and the man who had originally allowed him to do unpaid lab work at the hospital, and Dr. Julian Pribaz, a renowned surgeon. Because Pribaz was very progressive, independent, and not afraid to try new things, he turned out to be a perfect ally. But he had no time to be directly involved, so he just encouraged Dr. Pomahac—and truly believed that he could pull it off.
Dr. Pomahac followed a strategy wherein he did all the work but gave everyone else the credit. He knew that if a huge project like this one went wrong, it could end his career. But Dr. Pomahac intuitively thought this was the right project to bet on. The support of both senior doctors turned out to be very important.
Overcoming Institutional Objections
As Dr. Pomahac saw it, the big issue was how to put all the pieces together. The hospital had an institutional review board (IRB) that had to approve the project, which could take a long time; that same process for face transplants had taken 10 years in a comparable hospital in Cleveland. Additionally, the hospital had to come up with funding to get the project underway. No one had been to the organ bank, whose cooperation was needed to find donors. Dr. Pomahac reasoned, “If I get everyone involved early on, they will feel a part of the process and more sympathetic. Personal contact is critical to move beyond the formal processes.” He reached out to the IRB chair and brought some very dramatic before and after pictures of the French patient. He explained what he wanted to do, cited why he thought it was important, and asked for her advice about the best way to handle the process. She only gave him the rules for how to submit for approval, which would have happened for anyone who wanted to apply; however, she seemed moved by the discussion.
He went on to do the same thing at the New England Organ Bank. He gave their board (and four separate groups of transplant surgeons) a presentation on the topic, but he had the sense that they were suspicious that he was doing this only to boost his ego. As a result, he never pressured anyone to rush the process; he was always sure to put the patient’s interests first. The board offered to set him up to meet with their consortia meeting every three months. Dr. Pomahac sensed that they were testing him, so he let them take their time in order to make sure that it would never seem that he was personally trying to win a race. He recognized inwardly that though being the first in the United States would be nice and probably help attract funding, it was best to keep coming back to potential life-changing benefits for patients.
A Complex Integrated Plan—and Real Time Corrections
Dr. Pomahac then started the long process of writing everything up and bringing all the details together. He had to answer two substantial questions: (1) Because no one had done the operation before, how should it be designed in order to surgically make it happen? and (2) How could they get a donor? If the family coordinators at the organ bank wouldn’t ask families, it just wouldn’t happen. Because there is great emotion attached to the notion of giving up a face for a transplant, it was hard to imagine making the request—so this became a key element upon which Dr. Pomahac was forced to spend time. It was controversial and encompassed concerns about whether the recipient would look exactly like the donor, creating possibly awkward encounters with the family, and concerns about how to pay for a lifetime of immunosuppression drugs.
Dr. Pomahac’s strategy was to create the first protocol in a way that would eliminate all controversy. He suggested that they only do a partial face transplant to completely demonstrate that it would not transfer identity. As he explained:
We knew it shouldn’t happen, but to definitely show it, we proposed using a partial face, where even someone who worked with the person day-to-day wouldn’t recognize the original person’s face. We actually designed and published a study on this. Then we proposed picking patients who were already on the drugs because they had some other transplant to deal with immunosuppression.
This would be a perfect population that not only knew about risks and benefits of life on immunosuppression, but also did not represent any additional cost of drugs that would remain the same.
Outside Influences
As it happened, despite no planning for it, there was considerable media interest in facial transplants, a topic that apparently hooks widespread audiences. This turned out to be useful in reducing resistance among those that had to be convinced to cooperate, because good press serves to familiarize and legitimize unusual major changes.
Even with the improved protocol, some people at the hospital whose approval was needed were still hesitant to do so. Because chief of surgery Dr. Michael Zinner was reluctant to give the go-ahead, Dr. Pomahac’s supporter, Dr. Eriksson, came up with a wonderful idea: Dr. Joseph Murray, a Nobel laureate who had performed the world’s first kidney transplant at the Brigham in 1954, was being honored. Eriksson suggested inviting Dr. Max Dubernard, who had done the world’s first hand transplant and was part of the face team in France. Dubernard had been a fellow in Murray’s lab 40 years ago. An extremely charismatic and colorful person, he came to the Brigham and showed a video of the first patient with the hand transplant, playing a game of pickup sticks and then threading a needle, and another of the first face patient talking and smiling. No one had ever seen these videos, and all were amazed and moved. Then at the actual dinner, without prompting, Dr. Dubernard, during his speech, turned to Dr. Zinner and loudly declared, “Facial transplants are the future and you have to support them!” This of course helped move Zinner to become more supportive.
In the meantime, the restrictive protocol for patients with existing other transplants was not yielding any patients. Dr. Pomahac then had to persuade hospital officials to open the surgery to any badly disfigured patients. As they set about to select the first patient, he presented the original patient with the horribly burned face, Jim Maki, whose case had been so frustrating to him. There was a great deal of skepticism about whether Jim was the right choice; the entire surgical division was in the room, and the more willing junior people found it hard to convince the experienced practitioners. It took a lot of support from Eriksson and Pribaz to gain approval.
Dr. Pomahac did a conservative estimate of the cost and realized that probably no one would pick up the lifetime costs of the immunosuppression drugs. Working with the office of the physicians practice group that daily dealt with insurance companies, they managed to come to the following agreement: they would pick up the expense three months after the surgery. It turned out that language in the Medicare law generically said that drug costs would be covered “for suppressing rejection” but did not specify particular transplant organs, so facial transplants qualified. Each proposed patient requires a new approval process, but it becomes possible.
The hospital board then had to agree to pay for the first patient’s procedure and hospital stay. They were persuaded to go forward and to negotiate with Medicaid for the needed ongoing drugs. Chances are that the growing approvals and buzz prompted the willingness to go ahead.
Remembering Less Prominent but Still Important Stakeholders
Dr. Pomahac still had to do a bit more follow-up work with the family coordinators from the organ bank; unless he was able to genuinely convince them, they would never be able to persuade a donor’s family to cooperate. Dr. Pomahac went to visit them three more times, bringing along pictures and giving them extra time and attention. He worked to make them see that it would never be able to happen without them; he believed that the combination of the powerful pictures and letting them feel that they were important made a difference. He knew they had to share the vision. At first they would only approach a family who they thought would be open to the possibility—but that was almost no one. However, they’ve become comfortable with the prospect and are willing to ask any donor family. It also helps that Jim Maki is doing remarkably well.
Conclusions
It only takes a little bit of reading between the lines to recognize that Dr. Pomahac’s combination of intuition and analytical skills worked together to make him particularly effective. His experience as a chess player allowed him to see all the components that needed to be linked together and develop a reasonable sequence to follow. He was persistent in achieving his overall goal, but showed considerable flexibility in adapting what had to be done to get there. He also developed an excellent sense of what mattered to the different stakeholders, and combined methodical attention to detail with a clear eye on the ultimate prize.
Although Dr. Pomahac is ambitious, he was keenly aware any hint of this ambition might make some senior medical people less willing to cooperate. He needed to show them that his primary goal was to do what was right for patients, who were asking for the procedure despite the complications and risks. He noticed that people who might be considered less important than the doctors—like the family coordinators who had to recruit donors—also needed to feel that they were contributing to a grand vision. He recognized that personal contact was as important as bureaucratic procedure, and he made personal connections while carefully following recognized organizational requirements.
When confronted with skeptical surgeons and other doctors who were used to following systematic and deliberate research procedures, Dr. Pomahac used the vivid pictorial examples to transcend the abstractions. He showed how individuals had been unable to live visible, public lives until the transplants that allowed them to be fully human again. He didn’t put down the doctors’ commitment to research, nor his own long-term commitment to it; he simply proved that early adoption of the procedures could stimulate research, speaking to currencies both valued. Making a vision memorable can transcend considerable resistance.
Although this example is written in terms of the actions he took as a world class influencer, Dr. Pomahac certainly benefited from the efforts of many—“a little help from his friends”—and some good fortune on which he was then able to capitalize. He managed to influence some powerful individuals, and convince them of his deep care for alleviating the miseries of patients. When people believed that about him, they were more willing to help.
So far, four fortunate facial transplant patients have been the beneficiaries of Dr. Pomahac’s skill, determination, and focus, and he has helped advance an important medical, identity-saving process. It is only fitting that he was featured in the hospital’s year-end fund-raising appeal, and on the cover of the December 2011 issue of Boston Magazine, which highlighted “Top Docs and Amazing Medical Breakthroughs from 2011.”
Notes
1. Liz Kowalczyk, “A Dream Realized, and Lives Reborn: With Drive, Diplomacy, and Heart, a Young Surgeon Made Boston a Face-Transplant Leader,” Boston Globe (October 2, 2011).