Amy E. Gallo, MD
Assistant Professor of Surgery (Abdominal Transplantation)
Stanford University Medical Center
As the field of abdominal transplant surgery evolved, transplant surgeons fell under a number of hospital departments, including vascular surgery, general surgery, and urology. Financial and academic considerations dictate the reasoning for particular placement; however, what makes the most clinical sense is a multifactorial discussion and might be worth reconsideration in the changing medical environment. For large volume centers, perhaps a Transplant department is the future.
Currently, even for large centers there is no uniform departmental configuration for transplant physicians. The majority of programs have abdominal transplant surgeons under general surgery. Some kidney programs have surgeons solely in the urology department for both recipient operations and donor nephrectomies. Some surgeons, double boarded in pediatric surgery, remain in the division of pediatric surgery. The medical counterparts, hepatologists and nephrologists, are hired through the medical and pediatric departments, where transplant surgeons may or may not have hiring influence. These physicians may have a special interest in transplant or may be designated to transplant based on other staffing considerations. Fewer centers have transplant hepatologists and nephrologists as dually appointed in medicine and in surgery. Additional individuals vital to transplant success, namely intensivists, cardiologists, radiologists, anesthesiologists, psychiatrics, and oncologists, often have interest in transplantation but are hired based on their individual departmental needs and not the needs of the transplant program.
There is no doubt that in recent years, quality scrutiny of transplant programs has increased (1). Flagging by MPSC or CMS is a reality, to the extent that a program can be at jeopardy of closing based on outcomes. However, many of the transplant quality measures are unknown to participants outside the transplant community, while their involvement often directly affects patient outcomes.
A dedicated transplant department could control the flow of personnel in alignment with transplant recipient needs, list volume and management, and oversight of detailed quality measures. Research within the department across disciplines would be more accessible. The ability to collaborate could be more extensive, and the requirement to attend departmental activities outside the interest of transplantation could be curtailed.
A major consideration for continuing general surgery involvement is for residency training. Within the department of surgery, transplantation may have more clinical exposure to residents and in turn enhance recruitment into the field. I would argue, however, that in the current general surgery environment, transplantation is a low priority. It is no longer mandated as a formal rotation and is required only as a “transplant experience” (2). Exposure is often in the first and second years where the surgical experience, which often entices interest, is limited. The details of immunosuppression management is lost on short rotations.
If medical students alternatively could be exposed to a transplant science department, potentially it could then attract the best and the brightest early on in training like plastic surgery, ENT, and neurosurgery have over the years. With a bigger presence as a department with emphasis on medicine, research, and surgery, perhaps it will look more appealing to medical students as its own field instead of being buried within general surgery.
1: Snyder JJ, Salkowski N, Zaun D, Leppke SN, Leighton T, Israni AK, Kasiske BL. New quality monitoring tools provided by the Scientific Registry of Transplant Recipients: CUSUM. Am J Transplant. 2014 Mar;14(3):515-23. doi:10.1111/ajt.12628. PubMed PMID: 24502435.
2: Egle JP, Mittal VK. Program directors' perspective of transplant training during general surgery residency. Am Surg. 2014 Aug;80(8):796-800. PubMed PMID: 25105401.