Transcript
Robert Kirsner: Hello, everyone. I’m here today with Jeff Gurtner, who is Chair of Surgery at the University of Arizona and a premier wound healing clinician and researcher. I’m thrilled to have you here, Jeff.
Geoffrey Gurtner: Well, thank you for inviting me. I appreciate the opportunity.
Robert Kirsner: I want to explore over the next few minutes a little bit about how you got to where you are now, and then some of the motivations behind your work. We’ll dig into your work in a moment, but tell us a little bit of the backstory.
Geoffrey Gurtner: Yeah. So my first faculty job was at NYU, and NYU at that point was a private practice hospital. There were many, many plastic surgeons—I’m a plastic surgeon—who were on staff there. Basically, as the young guy on the faculty, I got whatever nobody else wanted to take care of, which tended to be wounds and difficult wound healing problems.
The Chair of Surgery at that time was a guy named Frank Spencer, who did a lot of trauma and vascular surgery in the Korean War, and said to me, “A diabetic heals about as well as a hole in your pants.” And I was like, okay, why is that? I really didn’t know anything about wound healing, and I just started inheriting a clinic full of wound patients at Bellevue where they were very advanced and had lots of comorbidities.
So I started trying different surgical approaches and then, at the same time, started a lab and was investigating why it is that diabetics don’t heal well. And so that’s kind of the beginning—this combination of work and lab.
Robert Kirsner: How has that combination played in your career, this interaction between both worlds?
Geoffrey Gurtner: Well, it’s really been a very satisfying career because, as you know, there are lots of things that we don’t know what to do for in a variety of clinical disciplines. If you don’t really have a lab or an investigational arm or opportunity, you’re kind of stuck. You just try things, and you throw things at it, and some work and some don’t work, but you never really know why.
Dealing with very difficult problems, like most wound problems, having a lab really let us go back to the laboratory and start asking why it is that diabetics don’t heal well, or what the challenges are. I can tell you, from my early surgical experience, there’s a book in plastic surgery called the Encyclopedia of Flaps. It was written by Berish Strauch at Montefiore and has all these different flaps. For foot wounds, I tried every single one of them, and I would say 95% of them didn’t work.
So I came to the conclusion that this was not primarily a surgical problem. I mean, you could do really heroic things like free flaps, but that’s not really scalable across the millions of patients who have diabetic foot ulcers, and diabetic patients also tend to be relatively high risk for six- to eight-hour operations. And so it kind of got me into, what are the molecular derangements that occur in diabetes, and can we correct them on a molecular level as opposed to with a surgical procedure?
Robert Kirsner: You’re a classic overachiever, not only in the sense that you’re an expert clinician and great researcher, but even within the research realm. As you highlighted your interest in understanding the molecular mechanisms of the diabetic foot ulcer, you’ve also been very interested in—and very successful in—advancing knowledge and hopefully translating that knowledge into practice for fibrosis and scarring. How are the two worlds wedded, or what is the overlap, and how does that fit into your grand scheme from your lab standpoint?
Geoffrey Gurtner: Originally, they were quite distinct projects. I also took care of burn patients and the long-term sequelae of burns, reconstruction after burns, and burn pathophysiology. They were really independent arms of the lab. But over time, they’ve kind of converged.
There seems to be fundamental biology—not surprisingly, I guess—but we’re starting to get to the fundamental biology of both impaired wound healing and overhealing, or fibrosis, or hypertrophic scarring. It seems that the inflammatory pathways and the immune system really are the drivers for diabetic wound healing, which doesn’t occur, and then also fibrosis.
So it’s a very exciting time. We’re starting to get far enough upstream that we’re no longer just focusing on the fibroblast, but we’re working on what activates the fibroblast to create too much scar or, in some cases, not cause enough healing. So it is actually converging, believe it or not, after 20 years.
Robert Kirsner: I will say this to the world: you’re always thinking about wounds. In fact, Jeff and I, a number of years ago, ran a marathon together. Early on in the run, surrounded by, I don’t know, five or ten thousand people, I tripped and fell and cut my hands and cut my knees. I was totally embarrassed. Of course, the first thing Jeff said was, “You’re going to get a biofilm in those wounds.”
So do you ever shut it off and stop thinking about wound healing? Or do your recreational activities just free up the brain to continue to think?
Geoffrey Gurtner: No, I’m always thinking about how humans and mammalian organisms respond to injury. So it’s not exclusively wounds. As I started a couple of years ago to be Chair of Surgery, as you look in trauma surgery, cardiac surgery, transplant surgery, a lot of the commonality of the complications involves wound healing and infection from wound issues.
Although it’s kind of seen as this niche activity that only affects diabetics, it really is ubiquitous through a lot of what causes health care to be inefficient and expensive. So I think it’s an underappreciated tsunami of medical and surgical complications in almost every area of medicine.
Robert Kirsner: Just in case people are wondering, at about the halfway mark of the marathon—we’d done a half marathon—Jeff said goodbye and went on and ran a great race.
Geoffrey Gurtner: There’s a story behind that, because I had never run a marathon, and I trained and said, “If I run a marathon in under four hours, I will never have to run another one again.” And I was on pace, and I made it. I actually cramped up in the twenty-third or twenty-fourth mile, but still got there before four hours. And I’ve never run a marathon again.
Robert Kirsner: There you go. So now you’re a clinician, you’re a researcher, and you’re building this Department of Surgery at the University of Arizona. How is that going, and how do those advancements fit into your whole view of solving medical problems?
Geoffrey Gurtner: It’s a good question because a lot of us who do clinical medicine tend to get kind of shunted to, “Oh, you just do clinical stuff so we can make money,” especially in surgery. That’s kind of what our value is to hospital administrators.
And I’ve kind of told my faculty, “You’re entitled to be curious. You’re entitled to wonder why this happened and to try to prevent it from happening again.” Because I do think that is the core strength and value that an academic department of surgery should have. I don’t think it’s obvious to hospital administrators in the short term, but in the long term, when you talk about quality—and things they also care about or have to care about because of third-party insurance and Medicare and Medicaid—those really do require thoughtful physicians to be thinking about how do we do this better.
So it has been a little bit of a change. I think people have embraced it because it really was just giving them permission not to always be grinding away on the RVU treadmill. Obviously we have to be productive, but most surgeons like doing surgery, so they tend to be productive. But I’ve kind of given the faculty permission to think about things and how to make things better. Maybe it’s go to the lab, maybe you go to the workbench, maybe you work with engineers. There are lots of different ways to make things better.
But I really do think that’s hopefully what the culture of the University of Arizona is becoming. And when I look back four or five years, it’s clearly a very different department than when I first got there.
Robert Kirsner: So fast forward, whatever that period of time is—whether it’s 10 years or 100 years—when you finally kind of give up your full-time career. Between now and then, or from the beginning of your career to then, if you had to say three things that you hope to accomplish or have accomplished, what would they be? What would you say: during my career, I’ve done this, or I hope to do this by the end of it?
Geoffrey Gurtner: Well, as you know, I’d like to bring a drug into the wound healing space—a small-molecule drug. We’ve been working on that, and there are lots of hurdles in the wound healing space from pharma and device companies. But we’re continuing to move things forward.
When we look at our drug in compassionate-use cases, where it’s not blinded and obviously not level 1 evidence, we’re pretty encouraged that there will be an impact there. So that’s one.
We have a clinical trial that’s about to start on fibrosis with a different small molecule. Having taken care of many burn patients, we can keep 95% of them alive now. But if you have a 60% burn, you are pretty disabled and disfigured for the remainder of your life. And it’s a problem that’s literally only skin-deep. So if we could make the skin regenerate, that would be a quantum leap forward. And I do think that’s possible.
I was just reviewing a big grant in Germany with a big German consortium, and I think we’re not as far away as we think. But I do think it will require big consortia to really lay siege to the problem. So that would be the second thing.
And then I guess the third thing would be to continue to have academic surgery and academic medicine be something that’s valued by society. I do think if it went the way of the dodo bird, the world and humanity would be in a much worse place. I don’t think we’d have medical advancements.
Although a lot of times people throw tomatoes at it and say it’s inefficient, it wastes money, and all that, I do think we’re the ones who generally come up with the cures and the advances. And I’d like to come up with a sustainable model for academic medicine that makes sense to taxpayers, makes sense to the federal government, makes sense to third-party payers, makes sense to patients, and is embraced. Because I do think we’re overall a beneficial facet of society, like art or literature or all these other things. If we go the way of the dodo bird, I think it’s a bad thing.
Robert Kirsner: So part of this vision of what you have and continue to accomplish is beyond just skin wounds—certainly your vision of academic medicine and surgery is. But what about those drugs? Do you see the drugs that you’re developing as something that could be generalizable beyond fibrosis in the skin? Imagine it helping fibrosis of the liver or the heart, or arthritis, or other things like that.
Geoffrey Gurtner: Yeah, we’re looking at that now because once you talk about the inflammatory system and the immune system being critically important in scar formation in the skin, you can ask the question: Is it also critically important in the heart? Is it critically important in the liver? And those are things you can manipulate, and you can measure what’s going on in the blood and what cells are in there.
So we’re excited that these fundamental processes involve the immune system, and they’re probably malleable. So yes, obviously that’s kind of the holy grail, but we think it’s possible. And we do see those cells in other fibrotic diseases. So we’re encouraged that potentially, if you block or manipulate the cells, you can have an impact.
The other thing that’s been really surprising—and we haven’t published this yet, so I can’t go into too much detail—is that they also seem to be involved in cancer. How they’re involved in cancer, and what the intersection is between fibrosis, the response to injury, and cancer, is a really interesting question that I think will probably be the next 50 years of research.
Robert Kirsner: Well, as I said, you are an overachiever. I was just hoping you’d cure fibrosis, but now you’re taking on cancer as well.
Geoffrey Gurtner: I’m not curing it. I’m not claiming to cure any of it. But I just think it’s interesting—the same biology, especially now with all the single-cell transcriptomics that we can do. We can really start to look at very rare cells that have a huge impact on all the downstream fibroblasts and other effectors. So it’s really, I think, a very fertile time to be looking at these sorts of questions. What’s the fundamental driver of pathophysiology?
Robert Kirsner: One last question before we go, because I could spend all day listening to you and talking to you about these issues. We’re in a moment in medicine and science where things are moving so rapidly, and it’s going to be transformed. If you had to take out your crystal ball five years from now, or ten years from now, how do you see science looking differently, or the performance of science looking differently, than it’s being done now?
Geoffrey Gurtner: I think it will probably have to be more efficient, more organized. Historically, academic medicine, because there was a fair amount of money available, kind of left people to their own devices, and they did what they wanted. Sometimes it was great, and sometimes it wasn’t great, and out of that, progress occurred.
I think we’re going to have to be more focused—disease-focused. I think basic science is critically important, but in the same way a lot of basic science came out of Bell Labs, there was always this thought of, okay, what could this practically be used for? Bell Labs had, I think, 11 Nobel Prize winners, and it was a corporate R&D facility.
I do think academic medicine is going to have to evolve in that way. I think you do the same things, but you have a more organized story to tell the taxpayer about, “The reason that this work on drosophila or bacteria is important is that we’re going to develop tools that might allow us to help patients with cancer.” Just connecting those dots at a marketing level, I think, is what’s needed.
Right now, there’s kind of a rear-guard resistance to, “Well, this is what we’ve always done.” And I just think that’s a losing battle in our current environment. So I would embrace doing all the same things, but organizing it and messaging it differently. I can’t imagine people saying, “Oh, that’s a bad idea.” But I do think when you say, “There are no constraints upon me,” it’s just hard to get people to say, “Oh, I want to write more taxes for that,” or “pay more money for that.” It’s a losing message. And I think we have to abandon losing messages and go with messages that might be more future-proof.
Robert Kirsner: Well, I think that’s a good point to kind of sum everything up. This podcast is about people and stories. To hear you tell your story—of where you came from and how you got involved with wound healing, how you developed your different laboratory interests, how you’ve grown your career to encompass creating a whole culture at an academic surgery department that hopefully will transform the whole institution, and then your vision of what you want to accomplish and what you see science accomplishing—hopefully, as people read your work and eventually use your drugs, they’ll remember the story of you telling your story, and that story will resonate, just as the story of science and how science is so critically important to advancing medicine will.
So, Jeff, thank you so much for being here. I think this was a fantastic segment, and I look forward to seeing this come to reality.
Geoffrey Gurtner: Well, thank you very much for inviting me. It’s been an honor.