Editor’s note: The Bulletin is collaborating with the American College of Surgeons (ACS) Surgical Research Committee to present a new series titled “Profiles in Surgical Research.” These interviews will be published quarterly and will highlight prominent surgeon-scientist members of the ACS, with a focus on past recipients of the Jacobson Innovation and Jacobson Promising Investigator Awards.
The first interviewee in this series is Michael R. Harrison, MD, FACS, a pediatric surgeon at the University of California, San Francisco (UCSF). Dr. Harrison has received international recognition for his pioneering work in fetal surgery.
Dr. Harrison was raised in Washington State before traveling east to study at Yale University, New Haven, CT, followed by Harvard Medical School, Boston, MA. He completed a general surgery residency at Massachusetts General Hospital, Boston, and a pediatric surgery fellowship at Children’s Hospital Los Angeles, CA. Dr. Harrison accepted his first faculty position at the University of San Francisco in 1978, where he continues to serve on the faculty as director emeritus of the Fetal Treatment Center. He performed the first successful fetal surgical procedure in 1981 and went on to receive numerous accolades and awards, including the Jacobson Innovation Award in 2002. He has co-authored more than 400 peer-reviewed publications and mentored many surgeon-scientists, including Michael T. Longaker, MD, MBA, FACS, the first recipient of the Jacobson Promising Investigator Award, presented in 2005.
Dr. Harrison was interviewed by Juliet Emamaullee, MD, PhD, chief resident in general surgery, Emory University, Atlanta, GA, and the Resident and Associate Society of the ACS representative to the Surgical Research Committee.
I went to medical school after I did my PhD; it was my interest in what I was studying scientifically that pushed me down this long road. I think it’s always good for those surgeons just starting their career to hear how people like you successfully conducted surgical research that led to clinical innovations. Did you always know you wanted to become a surgeon, or is that something that happened along the way?
My dad was a country doctor in a small town in the state of Washington. I think I just always wanted to be like him.
What about choosing pediatric surgery? Did this area become an interest as you went into your surgical training?
Yes. It is actually an interesting story because it involves one of the other Jacobson recipients. W. Hardy Hendren, MD, FACS, [2012 Jacobson Innovation Awardee] is a pediatric surgeon from Massachusetts General Hospital. I was a brand new, naive intern, and my very first rotation was on his service in pediatric surgery. I fell in love with it. I thought it was amazing. Actually, an experience in that first month of internship changed my whole life because he operated on a child with a diaphragmatic hernia, which was a beautiful operation. I got to sit with the boy for the next day or so, and then he died, like most of them do. That totally spurred my interest in [trying to fix complications] before birth.
When did you actually start engaging in scientific research?
I never considered myself a scientist. In those days, you could take time after your first two years of training and do something else. I applied to the National Institutes of Health (NIH) immunology lab and had a great time for two years studying immunology. That was my first exposure [to that kind of work], and it was enriching. Afterward, I integrated my two interests—pediatric surgery and the possibility of fetal surgery—with a little bit of science and immunology. The problem that really fascinated me and still hasn’t been solved is why the mother doesn’t reject the fetus.
When you finished your training, did you seek out a job that would allow you to incorporate research?
Absolutely. When I finished general surgery training I knew I wanted to be a pediatric surgeon. During that training, I knew that I wanted to focus mostly on fetal surgery. It was the only job I would really consider, so I looked around for institutions where this type of surgery might be possible. That’s how I ended up in San Francisco. It turns out that the pediatric surgeon, cardiologists, and scientists were developing the fetal lamb model to study congenital heart disease. I thought that would be the way to do fetal repairs in the uterus. That’s what we did. I came here, and we started operating on fetal lambs.
Were there a lot of naysayers at that time?
I often thought in retrospect that the circumstances regarding this situation were incredibly lucky for those involved. Well, part of it wasn’t luck because we, my family, decided there were only two places we could live along the west coast, and one of them was San Francisco. It turned out to be incredibly fortunate that UCSF was developing this new field of fetal surgery. They had incredible talent and the right attitude. They were the new folks on the block. I have often thought that I never could have done this or developed this field in any really established center like Harvard or Johns Hopkins [Baltimore, MD] or one of those fancy places, because they are too staid. Here, they cut me enough slack and provided enough helpful criticism, as opposed to obstruction, that we were actually able to do it. I don’t think there are many other places in the world where we could have developed this field.
Looking back, do you think you could have worked at one of those more established institutions? Did you make a personal choice to take a chance and go to San Francisco?
No, I actually scouted [them] out before I took the job here. I thought that this type of research would be possible here, not necessarily because of surgery, but because it had lots of resources, the kinds that would be needed to develop this field. I knew the Harvard system very well, and some other systems a little bit, enough to know it would be exceedingly difficult or impossible to conduct this type of research at those institutions.
How long did it take to prepare for your first clinical patient (a child with a urethral obstruction)? How did you go about it?
It took about four years. We set some standards for ourselves. We knew it would be such a fragile enterprise that if we had any bad experiences, we would be finished. We had to do it in animals first. We had to do the maneuvers in the most difficult animal model, non-human primates, to show it would be okay for the mother, that we could do what we intended to do surgically. So we had fairly high marks before we could offer it to the first patient.
Then, of course, we faced the huge problem of convincing our obstetric colleagues that it was the right thing to do. This could have been a real turf battle. “That’s my patient you are operating on! You don’t get to operate on them, that’s my business!” The pieces we needed in place were helpful, or at least tolerant, team members, including obstetricians, pediatricians, and anesthesiologists.
How were you dividing time between animal experiments and working on your patients?
Well, I was young enough to do both. I had been pretty busy from the start because I had joined a pediatric surgeon who previously had a solo practice at UCSF. It was just the two of us for around 15 years. We had a busy practice of wonderful, top-flight cases, referrals, and congenital conditions, as opposed to routine bread-and-butter operations. I was busy all the time. Then you would get to the questions I asked as a clinical surgeon.
The way we swung this deal was that the obstetricians and the neonatologists had a weekly meeting to discuss their problems. At the time, not many diseases were recognized in the fetus. So I started going to those weekly meetings and forming relationships with the prenatal diagnosis physicians, particularly those who performed sonograms. Then, we would say, “My gosh, this fetus looks like it has something we typically see after birth and that we correct surgically.” Then I would start suggesting that maybe we should fix it. I just hammered everyone about it for several years in those meetings until they started saying, “You know what? We are kind of thinking about fixing that.” That’s how we actually swung it—by attending those meetings and talking about specific cases. If you had a child and a family who now had a diagnosis and you were debating what to do, how to deliver him and so on, then people could rally around specific clinical problems.
How were you funding that early research with animals? Large animal research is very expensive.
It wasn’t at that time, surprisingly. It is incredibly expensive now. I came into a system in which people were doing large animal physiology all the time, almost every day. I could sort of work with them, and they would let me do some big stuff, and then we would order a few lambs. I don’t think we had to pay for too much in the first couple of years. And then, of course, we started to get grants, and we’ve more or less received NIH funding ever since. That is true for the clinical side, too; we eventually applied for studies, NIH trial grants, and so on. The animals were often paid for out of our clinical revenue, so that was doable.
The thing that is really difficult is paying for patients. Especially when insurance could deny everything, and the costs were huge, like millions of dollars, because the patients were in the intensive care unit. It’s a huge fight that I don’t think you could win today without some incredible source of funding. In those days, everybody was used to essentially giving away care. You know, when patients couldn’t pay, everybody sort of looked the other way. That was true for all the first fetal operations. The hospital basically absorbed the costs. We didn’t really even have to argue with the administrators very much, even though we didn’t have a formal program in place.
There was no formal credentialing? The family just agreed to consent and you were able to proceed?
That’s exactly how we did it. We would, of course, go to our ethicist and offer to go in front of the human research committee, which was a new body at that time. It was a constant dialogue, but no one ever told us to get rid of the program or asked who was going to pay for it.
Describe the process of applying for your first NIH grant. Did somebody help you through it?
No, we prepared it on our own. The first one I received was a March of Dimes’ Basil O’ Connor Starter Scholar Research Award. We had that for a couple of years, which got us started. Then we just taught ourselves how to write grants. No one really mentored or taught us; we just did it.
Were there any points in the process that were particularly difficult?
Yes, many of them. We had a lot of failures, of course. One example is when we first started repairing diaphragmatic hernia in utero. We decided that rather than just do this that we would actually apply to do a proper NIH-funded study, which we were awarded. In the middle of that study, things, particularly those related to licensing issues, started to go badly, and I think on several occasions the NIH set a moratorium. They said you can’t do anymore until you solve this or that problem. There were lots of problems, and starting and stopping those studies was incredible agony and required working with the bureaucracy.
How has receiving the Jacobson Award affected your career? Did you get to meet Dr. Jacobson?
It was just such a wonderful experience. Here’s a great story that involves some other folks. Dr. Jacobson is a surgeon in New York, and is an innovator who makes tools. He spun out this tool-making endeavor and in particular developed a little, lightweight hemostat. It was called a Jacobson. Hardy Hendren loved that snap so much, and we all learned to love it and to use it in every case. We called them “Jakes.” We didn’t even know they had the full name of Jacobson. We just said, “Hey, hand me the Jake.” It was such a cool thing to meet him and tell him that story.
What role has mentorship played in your career? It sounds like locally you had your senior partner as a mentor. Do other people stand out in your mind as mentors?
Yes, but not so much on the surgery side, it was on the experimental side, the fetal side, the obstetric side. I have had many wonderful colleagues. In terms of my mentoring of other surgeons, you will have to ask Dr. Longaker.
Have you found serving as a mentor to be an enriching experience?
Oh goodness, it’s the most fun. The most fun we have is having bright young people interested in what we are doing, usually joining us in the middle of their residency years or at some other point in their early careers. These are the best and most productive people, and I must say we have had some spectacular mentees along the way. They are scattered all over, and Dr. Longaker is a perfect example.
How did you find a balance between clinical practice, research, and home life?
I just liked everything I was doing, so it wasn’t a problem to fit it all in. The split between clinical and research was never a problem because in our work, the two were one and the same. There was no, “Let’s go to the lab and study a problem.” It was always, “Here is a problem in a patient. Let’s figure out what to do.” I didn’t have a distinction between clinical surgery and research.
In terms of personal life, that could have been a huge problem, but I managed to find a great wife. During that busy time, we raised four kids here in San Francisco. We lived close enough to the hospital that I could either run or walk to work, so I could be with them a lot. One of them is a third-year medical student, and she wants to be a surgeon.
What advice do you give to potential surgeons who come through your lab and really want to conduct research and be clinically active?
I don’t think I ever formulated that sort of advice. Our system is more of providing an example, and I think people see how much fun it is. I would just say do what you like to do and have some fun.
Do you see any big challenges facing young surgeon-scientists today? Obviously the funding environment is challenging, and a lot of academic departments are not as supportive of protected time for research.
Yes, it’s terrible. I feel bad looking at our young people now because there is so much pressure on them to justify their existence by making money and operating that it can be really difficult to succeed in science. Also, I think maybe the expectation of being a triple threat—I don’t know if it is even possible or even a good goal anymore. I say, if you want to do something creative, do something about what you see. I don’t think it’s right anymore to do what folks used to do, which is have one clinical life and one research life that aren’t connected.
Is there anything you think we can do as a community to support the concept of surgeon-scientists? It seems like it is almost a dying breed.
I totally agree. The usual answer is that departments at teaching hospitals need to encourage and pay for it, to allow for surgeons to take time off to do research. But that is an old answer. I can’t think of a new answer for that situation.
How often do you hear back from patients and families from all of these studies over the years?
All the time. It’s wonderful. I’m not clinically active anymore, otherwise I would still be seeing them. I still have contact with my first successful fetal surgery patient; he sends me cards. Seeing the benefit is absolutely the best part of it.
What do you think is your greatest accomplishment so far?
Clinically, moving this field forward has inspired you from day one—that has to be a great accomplishment.
Yes, it’s always really fun to do something brand new. I guess that would be the best accomplishment, doing something completely new.