by Caroline Lupfer Kurtz

More open-heart surgeries are performed in a year at St. Patrick Hospital and Health Sciences Center in Missoula than at Stanford Medical Center in Palo Alto, California.

The National Institutes of Health recently committed $7 million to establish a Center of Biomedical Research Excellence at The University of Montana for the study of brain function and disease.

Every summer, hundreds of surgeons, nurses, patients and students flock to western Montana from around the country, and even the world, to learn, practice and benefit from the latest advances in cardiac care and neurosciences.

And only here is there a joint university-community-hospital effort to remind the public and health professionals alike of the essential human dimensions of medicine.

Sidebar Heart Institute a
Godsend for Foreign Student

Big things are brewing in the world of medicine and medical research in Montana, thanks in large part to a practically unheard-of relationship between a state university and a local community hospital. In the absence of a medical school and associated teaching hospital in Montana, UM faculty members and St. Patrick Hospital staff are building a variety of partnerships that are changing the picture of health in the state. Specifically, the collaborations aim to strengthen cutting-edge research, develop new surgical procedures and patient therapies, and promote the humanistic aspects of medical practice and health care. Future alliances may include an area health-education center that will focus on delivering continuing education and training to meet the needs of health professionals in the western part of the state.

The achievements and prospects of the International Heart Institute of Montana, the Montana Neuroscience Institute and the Institute for Medicine and Humanities, as the current three partnerships are formally known, are due to a growing confluence — partly fortuitous, partly orchestrated — of people and ideas, hospital President Larry White says. Although the synergy is hard to quantify, conversations with faculty, researchers and medical professionals reveal a belief that the University and the hospital act to complement each other and add importantly to each others’ success. Together they offer more than either institution could by itself.

“It’s a case of the whole being greater than the sum of its parts,” says UM President George Dennison.

“There’s no question these collaborations are having a big impact on the quality and quantity of health care available to Montanans,” he adds. “A larger infrastructure can support more specialties and new research efforts, which then become a magnet for new services and procedures. And the research being done between the University and hospital will benefit the state both financially and in terms of quality of life for people.”

The following are snapshots of the UM/St. Patrick institutes and how they do or might soon benefit the people of Montana.

High-touch, not high-tech
Oldest and arguably most far-reaching of the partnerships, the Institute for Medicine and Humanities brings the insights of literature, philosophy, ethics, history, religious studies and anthropology to bear on the way society views illness and cares for people who are sick or dying. Its 13-member executive board is composed of nurses, doctors, University faculty members and community members.

Sidebar Healing With Music

“So much of medicine is high-tech,” White says. “After a point that becomes dehumanizing. The Institute for Medicine and Humanities focuses on the ‘high-touch’ aspect of medicine, the big questions. What are the lessons of the humanities learned over the centuries? How do they relate to the human condition dealt with in hospitals and medical practices? How are these lessons pertinent to people who give care?”

To address these and other issues, pediatric neurologist Herbert Swick uses the poetry and prose of such well-known physician-authors as Anton Chekhov, William Carlos Williams and contemporary writers Richard Selzer, John Stone and Susan Mates in his undergraduate honors course, Doctors’ Stories.

“The course is a provocative way to get students to think about ethics of health care, about death and dying, about illness and healing,” says Swick, who became director of IMH a year ago. “Literature makes these issues accessible.”

Literature also helps physicians put into perspective what they see every day and to articulate their own experiences, such as when a patient dies, Swick says.

Grappling with such problems, Swick believes, may benefit premed students — and the people whose lives they will eventually touch — but he also is pleased that many nonscience majors elected to take Doctors’ Stories. He plans to offer the course again and integrate some of the curriculum into other literature classes on campus and through the Practical Ethics Center and the School of Pharmacy and Allied Health Sciences. He also hopes to set up a mentoring program so students can spend time with physicians in the community to learn about the realities of a medical practice.

Sidebar Helping Hands: Students Learn by
Doing in COT Health Professions

The work of IMH extends far beyond campus, however. For years the institute has offered annual meetings and numerous workshops and lectures on a variety of topics, including the advisability of physician-assisted suicide, the spiritual dimensions of healing, moral concerns about managed care, the place of alternative medicine in current medical practice, medical ethics in literature and the history of medicine in America. Swick says that such programs help the public face the social realities that medicine deals with — who gets what care and how much, the quality of end-of-life experiences and how illness can profoundly change a life.

The institute’s programs take diverse forms, from brown-bag lunches to all-day conferences to theater and discussion sessions. Last October, a symposium titled “Careers, Callings and Conscience: Reflections on Contemporary Professional Life” brought together physicians and other health professionals, attorneys, teachers, civic and religious leaders, and others from Montana and elsewhere to encourage a renewed sense of “civic professionalism” — a shared sense of calling in the professions and of duty toward one’s community.

To Swick’s knowledge, the institute is unique in this sort of outreach. Certainly it’s the only one he is aware of that is jointly sponsored by an undergraduate institution and a community hospital, rather than housed within a school of medicine. He hopes what is happening in Missoula will become a model for other communities.

In the past, some IMH programs have been repeated to audiences in Polson and Hamilton. More recently, Swick worked with students at Kalispell High School on a project dealing with the ethical implications of the human genome project. He has given seminars on professionalism and professional values to staff members at other medical centers across the nation and is on the Montana Committee for the Humanities’ speakers list. He frequently gives talks on the interrelationship of medicine and the humanities, especially music, at professional meetings. And with some additional support, Swick would like to create a weekly radio program “on matters medical and humanistic” as he did very successfully some years ago in Milwaukee.

“The science of medicine is exploding,” Swick says, “but the core of medicine still is the special relationship between patient and physician, and it’s a rich relationship in both directions.”

The heart of the matter
In summer 1999 Nels Thoreson needed surgery to repair blocked arteries in his heart. Because of his history of strokes, doctors at the International Heart Institute of Montana decided that Thoreson should not be on a cardiopulmonary bypass machine, which circulates and oxygenates blood in place of the heart. Instead, surgeon Matt Maxwell used special instruments to sew new vessels into Thoreson’s still-beating heart.

Two months later Thoreson’s wife, Kathleen, needed coronary artery surgery as well. In her case, Maxwell used a procedure called endoscopic vein harvest to obtain the saphenous vein from her calf to create the bypass. Rather than slicing open the leg from knee to ankle, endoscopic harvest uses small, 2- to 3-inch incisions and a tiny fiberoptic camera to obtain the necessary replacement vessel.

Both Thoresons are feeling fine more than a year later, thanks to the use of such minimally invasive techniques at the Heart Institute.
The heart institute is the second partnership between UM and St. Patrick Hospital. It was created in 1995 to build on the hospital’s existing expertise in cardiac care and to take advantage of faculty and campus resources in physics, biochemistry, mathematics, and cellular and animal biology. More than 5,000 cardiac procedures are performed each year at the hospital, including more than 450 open-heart surgeries by institute staff. Between 50 and 60 of the patients come from outside the state.

“What’s so unique about the institute is the close working relationship we have among researchers, cardiologists and surgeons,” says President and CEO Carlos Duran, who also is chair of cardiovascular science in UM’s pharmacy school.

Molecular biologist and geneticist Douglas Coffin is an example of this relationship. Currently a UM associate professor of pharmaceutical science, Coffin began working with the heart institute when he was at the McLaughlin Research Institute in Great Falls. He is continuing studies begun there of how the heart generates new blood vessels in areas that have been damaged by heart disease.

As plaque builds up and closes off blood flow in coronary arteries, healthy vessels send off new branches to supply the deprived area, Coffin says. He and Duran are looking for ways to enhance this process in seriously ill patients. One way is by using transmyocardial laser revascularization (TMR), in which a laser beam bores tiny holes in heart tissue, spurring the organ to generate more blood vessels.

How this happens on the biochemical level is still unknown, but Coffin is focusing his work on small proteins called growth factors that are produced in every tissue of the body to assist in wound healing. He has genetically engineered 10 different laboratory strains of mice to make more or fewer of these regenerating molecules and is studying how each type responds following TMR surgery.

“We’d like to know how TMR specifically affects the physiology of the heart so we can design drugs that would do the same thing but less invasively,” Coffin says.

In a completely different sort of study, UM mathematicians are using data from the hospital’s sonometrics experiments — three-dimensional recording of movement using tiny crystals placed in multiple locations on the heart — to make models that can be used to create better ways to repair heart valves and perhaps to help develop a new operation for heart failure.

A global perspective
The “international” in the institute’s name is not an overstatement. The program has gained an international reputation under the direction of Duran and fellow cardiac surgeon James Oury through its fellowships, workshops and annual heart-valve symposium, which this year attracted participants from 19 countries.

“Once upon a time no one in the cardiology world knew where Missoula was,” Duran says. “Now they all know.”

Duran himself recently returned from a round-the-world tour, first to Cancun, where he was part of the organizing committee for a cardiac surgery meeting. He then traveled to Thailand, Indonesia, Singapore and Borneo to perform special-case operations in each of those countries. Many of the patients needed heart-valve replacement or repair, a field in which Duran is a pioneer.

Heart institute research and experimentation has led to vastly improved methods for using a patient’s own pericardium — the tough, stretchy material that covers the heart — to fashion new valves. By treating the pericardium chemically and fitting it to a customized mold, surgeons can prepare replacement valves in the operating room for a fraction of the cost of mechanical or animal valves and without the risk of rejection.

Developing countries, in particular, are very interested in this technique, Duran says, because of the lower costs involved. The institute has fostered a new company in Singapore that is beginning to manufacture the molds used to create aortic valves.

Another research effort about to debut is the manufacture of pre-packaged, freeze-dried blood vessels to be used for coronary bypass and peripheral vascular repair. More than a million such operations take place worldwide each year, Duran says.

Biochemist David Cheung, head of the institute’s tissue-engineering lab, has successfully modified mammary arteries from cows and pigs to create conduits four millimeters in diameter and of varying lengths. Currently there is no such functioning product less than six millimeters in diameter.

To capitalize on this invention, the institute has formed a new company called Philogenesis Inc., in partnership with the company Labcor and venture capitalists, to begin making the treated vessels. Clinical trials in humans are under way in Brazil, with U.S. Food and Drug Administration approval expected in the next couple of years. Eventually, Duran expects that the annual manufacture of an anticipated 150,000 grafts will require two or three small factories around the world, one of which could be in Missoula.

In addition to research projects with University faculty, IHI offers training in advanced surgical techniques through symposiums and sponsors one or two fellows each year to work in the tissue-engineering lab. So far the fellows have been surgeons from Korea, China, Japan, France and Germany and two bioengineers from Singapore. They stay connected with the institute for the rest of their careers, Duran says.

The institute also helps undergraduate students gain research experience during the summer, and two biological sciences graduate students are working on advanced degrees under the supervision of IHI members.

Finally, IHI does not just focus on immediate care. Members of the nursing staff have developed an elaborate data bank of patient information, and they conduct regular surgical follow-up assessments of their open-heart patients.

“A true evaluation of surgical success and quality of care is long term,” Duran says. “The fact that the patient leaves the hospital is only part of the story.”

At the invitation of other communities, the institute has started reaching out to build satellite operations. By spring or early summer, IHI, in agreement with Kalispell Regional Medical Center and St. Patrick Hospital, will hire a cardiac surgeon to handle heart cases in Kalispell. Kalispell nurses already have been coming to Missoula for specialized courses in preparation for the new services. A similar connection is under discussion between IHI and Benefis Hospital in Great Falls. The Kalispell program will begin with less complex cases, Duran says, but ultimately “we want no difference in the two centers in terms of patient care.”
Brainstorming: Montana Neuroscience Institute.

Montana’s big skies, its oceans of prairie and origami mountains make for beautiful country but can be a challenge to delivering timely health care. For a person experiencing a stroke, for example, how fast he or she can get to care may mean the difference between recovery and perhaps lifelong impairment.

“When a stroke occurs, the initial injury is localized,” says Pamela Meck, clinical research coordinator at the Montana Neuroscience Institute, the latest partnership between UM and St. Patrick Hospital. But secondary damage continues to occur as injured brain cells dump toxic quantities of neurotransmitters into the brain, causing more cell death.

Meck says many people do not realize what their sudden weakness, blurred vision, speech difficulty, dizziness or headache may mean, and they wait a day or two before coming to the emergency room.

“There is the misperception that if you have a stroke you will either die or that’s as bad as it will get,” she says. “That’s not true. We need to stop the secondary damage in the early stages so the effects are not so catastrophic.”

That’s part of what the neuroscience institute is all about — integrating basic research on such problems as stroke, brain tumors and spinal cord injury with the latest procedures and rehabilitation therapies for patients.

“The greatest thing the institute does and will do is be a conduit for the flow of ideas between the campus and the hospital,” says Richard Bridges, professor of pharmaceutical science and a founding member of the institute.

“It’s a two-way street,” he adds. “Whenever physicians want to use the newest drugs or procedures to help patients, they also need access to the latest research. Being connected with University researchers makes it possible for the hospital to recruit cutting-edge physicians. And if University researchers want to get in on the early clinical trials of new drugs, we need the physicians who are approved to use them.”

The type of research that connects basic and clinical research is called translational research. And this sort of work is at the heart of biotech and economic development in the state, Bridges says.

“Translational research leads to the development of new drugs, devices and protocols, all of which are patentable,” he says. “Some of these can be used to create new companies and jobs, which can attract more businesses and create a community where people want to live and work.”

At UM a growing number of researchers are working on diverse aspects of the central nervous system — from the neurochemistry of reproductive hormones to the use of certain plant extracts as remedies for headaches and migraines. Their studies primarily focus on how brain cells talk to one another via chemicals called neurotransmitters and how this signaling process can be interrupted by disease or injury.

Bridges’ own research interests focus on the neurotransmitter glutamate, a key molecule in the brain’s ability to learn and remember. One project that involves the role of glutamate movement in certain kinds of brain tumors caught the attention of neurosurgeon Nick Chandler, who coincidentally moved to Missoula the same year as Bridges.

In addition to his neurosurgical practice, Chandler was interested in studying similar glutamate issues in brain tumors and thought he and Bridges could collaborate. Their association soon blossomed into something far beyond the bounds of a single research project.

One of the earliest accomplishments of the fledgling institute was the creation of a tumor bank at the hospital, which researchers can access for various purposes. The bank currently contains 103 samples of tumors from patients at St. Patrick Hospital and is the biggest available source of such material between Seattle and the Mayo Clinic in Minnesota.

Chandler sees a certain similarity, in fact, between independent research institutes such as the Mayo and the Cleveland clinics and the partnerships between UM and St. Patrick.

“We’re essentially starting a medical school environment where no medical school exists,” he says, which is exactly what those other organizations did.

Most administrators of hospitals this size would never conceive of these partnerships, he adds, and Chandler considers Larry White progressive in this regard.

Like the Heart Institute, the Montana Neuroscience Institute increases its reputation nationally by holding a number of professional meetings and symposiums for physicians and nurses. Chandler hopes to see an increase soon in the numbers of neurosurgeons and neurologists working with the institute. In 1993, some 275 neurosurgeries were performed at the hospital. By last year, that number had increased to nearly 1,000. Some of that increase is due to population growth in western Montana. But patients also are coming from farther away because of the services offered here.

The partnership has paid off in other ways, too. Recently, UM received almost $7 million from the National Institutes of Health to create the Center of Biomedical Research Excellence, which focuses on investigations into the ways brain cells function at the biochemical level and how those functions change with disease or injury, such as Alzheimer’s or stroke.

Bridges says an important reason the University was awarded this grant was its close ties with St. Patrick Hospital. The award was one of 19 funded through the NIH Institutional Development Award program to increase biomedical research in states that have not fully participated in NIH funding before. With it, Bridges says, UM will be able to buy more equipment, hire scientists doing cutting-edge research, recruit and train top graduate students and increase neuroscience course work and research opportunities for undergraduates.

The IdEA grant also will help attract funding for another potential joint enterprise, a Montana Stroke Center in Missoula. While there is a nationwide network of stroke centers, none exists in Montana, Idaho or Wyoming, and UM and St. Patrick Hospital are hoping to remedy this deficiency. Because stroke involves the cardiovascular system and the brain, the proposed center would draw heavily on both the Heart Institute and the Montana Neuroscience Institute for patient care and basic research.

With the cooperation of the medical community throughout the state, such a center would provide people in Montana and the surrounding region with the latest stroke treatments and rehabilitation therapies. It could function as a central clearing house to train medical personnel in the diagnosis and treatment of stroke in rural communities, carry out basic and clinical research on stroke, and create a comprehensive public awareness program on stroke risk, warning signs and the importance of immediate medical treatment.

“We’re looking at using the University-hospital setup as a model to address many neurological and neuroscience issues that can’t be done in an urban center,” Bridges says. “Stroke management in rural areas is a prime example, when time is of the essence.”

For more information on the UM-St. Patrick Hospital partnerships, contact:

• The Institute for Medicine and Humanities,
(406) 329-5662
• The International Heart Institute of Montana Foundation, (405) 329-5668
• The Montana Neuroscience Institute Foundation,
(406) 243-51