BehindTheMedspeak: Steve Jobs' Liver Transplant

Early last Saturday morning, June 20, 2009, Yukari Iwatani Kane and Joann S. Lublin broke the news in the Wall Street Journal (WSJ).

My first reaction upon learning about it in that day's dead tree iteration of the paper was not surprise that he had the procedure but, rather, amazement that such a big, important secret could have been kept for two months.

Astounding.

Wrote Kane and Lublin, "At least some Apple directors were aware of the CEO's surgery. As part of an agreement with Mr. Jobs in place before he went on leave, some board members have been briefed weekly on the CEO's condition by his physician."

I wonder how many other reporters had the story but, out of loyalty to/friendship with Jobs, chose to sit on that knowledge the same way every newspaper and news organization around the globe did with the facts surrounding the kidnapping of New York Times reporter David Rohde by the Taliban seven months ago.

You can bet that if Drudge or the Huffington Post or any of Nick Denton's or Jason Calacanis's bloggers had gotten wind of Jobs' surgery it would've been reported in a Tel Aviv yoctosecond.

Aside: Q. What's the shortest known interval of time? A. That between a traffic light turning green in Israel and horns sounding behind the first car.

But I digress.

Rex Hammock of  Nashville, Tennessee,  in a June 22, 2009 RexBlog post, contended that Steve Jobs himself  "leaked" the story to the Wall Street Journal, following what he called Rule 1 of corporate communications, namely, "Release bad news on a Friday night."

I'll tell you a reason that hasn't been talked about much that led to Jobs having the procedure at Methodist Hospital in Memphis, where the liver transplant team is led by Dr. James D. Eason , rather than in the Bay Area or Southern California.

Rex Hammock, in his post cited above, wrote, "One of Steve Jobs’ local newspapers, the San Jose Mercury, like all newspapers, was forced to interview transplant surgeons who can only speculate about the surgery and why Jobs chose Tennessee. However, because the paper is treating the story as a “local” one, it’s worth noting what Lisa Krieger, one of its reporters, heard from longtime transplant surgeon Dr. Oscar Salvatierra of Stanford University’s School of Medicine, who speculated why Jobs traveled to Tennessee for the procedure, 'It is likely not a wait-list issue but rather one of maintaining privacy. I would suspect he sought to stay away from the area in which he works, and where people know him.'"

Yes, that's why he chose Methodist Hospital in Memphis. More on why I believe that was the venue later in this post.

Certainly the waiting list is shorter in Tennessee (3.8 months at Methodist Hospital according to Denise Grady and Barry Meier's story which appeared on the front page of yesterday's New York Times Business section) than in California, where Jobs lives and works.

Kane and Lublin wrote, "The specifics of Mr. Jobs's surgery couldn't be established, but according to the United Network for Organ Sharing, which manages the transplant network in the U.S., there are no residency requirements for transplants. Having the procedure done in Tennessee makes sense because its list of patients waiting for transplants is shorter than in many other states. According to data provided by UNOS, in 2006, the median number of days from joining the liver waiting list to transplant was 306 nationally. In Tennessee, it was 48 days."

That's important.

But also very important to the close-to-the-vest CEO is privacy and secrecy.

Said Silicon Valley marketing veteran Regis McKenna, in a story in yesterday's New York Times, "But what most people don't understand is that Steve has always been very personal about his life. He has always kept things close to the vest since I've known him, and only confided in relatively few people."

There is no possible way to keep news of someone as important as Jobs having surgery of this magnitude secret in a top-tier California hospital.

I mean, not to blow the horn of my alma mater (Go Bruins!) but UCLA Hospital's liver transplant surgeon-in-chief, Dr. Ronald Busuttil, has done more of these procedures than anyone in the world.

You could look it up.

So world-class expertise was just a short plane trip down the coast.

Busuttil's a great guy: when I was at UCLA on the anesthesiology faculty, he was a junior attending in general surgery.

One night my girlfriend's best friend's husband, a radiology resident at UCLA, came down with appendicitis.

The guy's wife asked if I would personally do his anesthesia and not let a resident be involved, as would normally be the drill.

I said sure, and called Busuttil and asked him if he'd personally do the surgery as opposed to supervising one of his residents.

I'd worked with him enough over the years to know how excellent he was technically.

Instantly he agreed.

That was the fastest appendectomy — from the time the guy entered the OR to when he left — I've ever been part of.

But I digress yet again.

The problem with being famous and having your procedure done at UCLA is that news of it is likely to get out no matter how tightly you try to hold it.

I remember back in the day, when Elizabeth Taylor was a patient there on my service while I was doing my general surgery rotation during my fourth year of medical school.

There were security guards at the desk of her floor; no one but her attending surgeon and a particular senior resident were allowed into her room to see her on our twice-daily rounds.

The rest of us cooled our heels while they examined her.

Nevertheless, news leaked out as a result of reporters impersonating nurses, orderlies and the like; desk clerks were bribed to allow people to see her chart, which was otherwise kept locked up.

The same thing happens every time a celebrity checks in to a big L.A. hospital.

And with the number of services involved in a liver transplant, there's no way secrecy could've been maintained had Jobs had his procedure there.

So that's why, along with the ultra-short waiting list — months as opposed to the usual years — he went to Memphis.

Of course, as Grady and Meier pointed out, it helps to have a private jet fueled and ready 24/7 to take you to any transplant center in the continental U.S. within six hours of getting a call that an organ is available.

Now, as to why you can be certain Jobs had his transplant at Methodist as opposed to the other two hospitals in Tennessee — Le Bonheur Children's Medical Center in Memphis and Vanderbilt University Medical Center in Nashville — that perform them:

1. "A spokeswoman for Le Bonheur said the hospital doesn't perform liver transplants in adults," said the WSJ story.

2. According to the WSJ piece, "A Vanderbilt spokesman said it didn't treat Mr. Jobs," while "A spokeswoman for Methodist University said Mr. Jobs isn't listed as a patient there."

Sara Patterson, in a June 21, 2009 Memphis Commercial Appeal story, quoted the Methodist spokeswoman, Ruth Ann Hale, as saying, "We've never had a patient by that name in our admissions directory."

Scott Noll, in a June 22, 2009 story on WREG.com, wrote, "Hospital says there's no record of Steve Jobs there, but spokeswoman admits that information can be left out of logs."

OK.

Think for a second: would you put Steve Jobs' name on a list of patients if you wanted it to stay quiet? Not likely. Think "Rob Tasks" or something of that ilk.

3. Vanderbilt's waiting list is currently about 17 months as opposed to less than 4 months at Methodist, according to Grady and Meier's story.

What's Jobs' prognosis?

In a word: guarded.

Liver transplantation is a big, big deal: unexpected, sometimes life-threatening complications can occur seemingly out of nowhere months or years after the initial procedure.

Patients have to take powerful immunosupressive drugs, themselves capable of causing side effects and compications, for the rest of their lives to prevent rejection of the foreign organ.

Besides which, experience is limited when it comes to transplantation as treatment for metastatic pancreatic neuroendocrine islet cell tumor, the most likely reason Jobs underwent the procedure.

According to John Lauerman's June 22, 2009 Bloomberg.com report, "The top 10 U.S. transplant centers have probably performed fewer than 100 of the procedures to treat the spread of neuroendocrine tumors overall."

That's compared to an estimated 6,500 transplants performed in 2005 alone, according to the American Liver Foundation.

Worth mentioning is that on January 16, 2009, Bloomberg.com reported that Jobs was considering a liver transplant.

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Note added 7:02 p.m. Wednesday, June 24, 2009: Last evening Methodist Hospital released a statement confirming Jobs' transplant there.

Methodist then raised the full disclosure ante by having Jobs' surgeon, Dr. James D. Eason, give a televised press conference today in which he responded at length and in detail to various concerns and issues that have arisen as a result of the procedure.