Zoe A. Stewart, MD, PhD, FACS
Surgical Director Kidney, Pancreas, & Living Donor Transplant
Assistant Professor of Hepatobiliary and Transplant Surgery
University of Iowa Organ Transplant Center
There has been extensive debate in the past few years about the number of transplant surgery fellowship positions. While we may never reach a consensus about the “correct” number of fellowship slots, these discussions have highlighted the challenge to recruit the best U.S. trainees into transplant surgery.
General surgery training has seen dramatic changes in the past two decades. Implementation of the 80-hour workweek has impacted trainee expectations of work/life balance and potentially reduced resident exposure to transplant surgery. There has also been an explosion in subspecialty training options (breast, endocrine, minimally invasive, bariatric, surgical oncology, colorectal, hepatobiliary, trauma/critical care, burn...to name a few). Further, several specialties (Cardiothoracic, Vascular, Plastics) now enroll some of the most talented medical students directly into “Integrated” residency/fellowship programs, depriving abdominal transplant surgery of the opportunity to recruit these students. Finally, the number of women in surgery continues to rise, from 25 percent in 2003 to almost 40 percent in 2013.
Numerous factors contribute to the selection of a surgery subspecialty fellowship: intellectual appeal, clinical exposure during residency, an influential mentor, fellowship competitiveness, job opportunities, and lifestyle. While the relative importance of these factors vary between individual trainees, all are vital to the decision-making process. The intellectual appeal of transplant surgery is undeniable. For decades transplant surgery has been perceived as a leader in innovation for all aspects of surgical patient care. However, even liver transplantation is now often considered “old hat” by medical students and residents. Additionally, many subspecialties now outcompete transplant surgery for surgical trainees who desire to be at the forefront of new surgical techniques in robotic, minimally invasive, and endovascular approaches.
In the past decade, surgical resident exposure to transplant surgery rotations has been in jeopardy of being eliminated. In 2006, the Residency Review Committee (RRC) in Surgery proposed removing the transplant surgery rotation from the core education requirements, citing consistently poor resident evaluations of their transplant educational experience. ASTS developed a corrective action plan to address the RRC concerns and implemented a new resident curriculum. While ASTS won a stay of execution for the resident rotation in transplant surgery at the last hour, the RRC is continuing to closely monitor resident and Residency Program Directors’ feedback. In a 2010 follow-up study, ~60 percent of 648 surgery residents reported favorable self-assessment scores on knowledge of immunosuppression management and transplantation ethics, in addition to the surgical skill set they acquired during their transplant rotation1. A majority of residents also agreed that transplant surgical skills would assist them in their careers and were applicable to other surgical subspecialties.
Unfortunately, transplant surgery is the least competitive surgical subspecialty for U.S. graduates. The 2014 NRMP Match Data reported 20 U.S. applicants for the 73 Transplant Surgery positions (0.27 applicants/position). In contrast, Pediatric Surgery had 59 U.S. applicants for 38 fellowship positions (1.55 applicants/position)2. While we can debate what the denominator should be for transplant surgery fellowship positions, clearly we need to make transplant fellowship a desirable commodity to attract the very best U.S. trainees.
Debate on the number of transplant fellowship positions has often focused on the perceived lack of job opportunities for fellowship graduates. However, recent data from several sources has failed to validate this concern. ASTS fellowship exit survey data from 2010-2014 found that annually 80-90 percent of U.S. graduates (24-35 graduates annually) obtained transplant jobs and >80 percent of these graduates got positions transplanting their desired organ(s). Nearly identical results were obtained in a study of an older cohort (2003-2005), with >90 percent of U.S. trainees getting transplant jobs and again over 80 percent getting positions transplanting their preferred organ(s)3.
There is little question that transplant surgery is globally viewed as having one of the poorest lifestyles of any surgical subspecialty. Resident perceptions about lifestyle are strongly influenced by their mentors. Trainees are unlikely to consider transplant surgery if their mentors are constantly complaining about their call schedule or having to operate at night. We have a tremendous responsibility to impart our passion for what we do on a daily basis to medical students and residents. Finally, I have personally found it very exciting to observe the steady rise in the number of female transplant surgeons. Hopefully this trend will continue and help to foster to the ongoing recruitment of female surgical residents into transplant surgery…from my perspective.
1 Schwartz J.J., Thiesset H.F., Bohn J.A., et al. (2012) Perceived benefits of a transplant surgery experience to general surgery residency. J Surg Educ 69(3): 371-384.
2 National Residency Match Program. (2014) Results and Data Specialties Matching Service. www.nrmp.org
3 Reich D.J., Magee J.C., Gifford K., et al. (2011) Transplant surgery fellow perceptions about training and the ensuing job market--are the right number of surgeons being trained? Am J Transplant 11(2): 253-260.