What's Your Perspective?

Growing the Pipeline of Future Transplant Surgeons

Dageforde Photo JPGLeigh Anne Dageforde, MD, MPH
Massachusetts General Hospital

Transplant Surgery is an amazing field so let’s get students and residents involved early!

From my perspective, transplant surgeons have one of the most exciting careers in medicine. We have a unique role in turning the devastating experience of death into a life-giving opportunity for multiple patients. Our practices are a combination of time spent in the clinic and the operating room. We do day surgeries and large complex operations. Our patients require equal parts medical knowledge and surgical skill. Some of our patients are rescued from the brink of death after lingering in the MICU with a high MELD awaiting their liver transplant. Others come from home for their preemptive living donor kidney transplant. We treat patients of all ages with diverse social situations and backgrounds. Our role in the field can be customized by organ-type and interest. Many of us follow our patients for years building lasting relationships with them and their families reminiscent of a relationship with a primary care physician. Transplant research is novel and cutting edge, and more work needs to be done. What a great field!

If all this is true, then why is the demand for an abdominal organ transplant fellowship so low?

Transplant surgery is one of the least competitive fellowships for US trained general surgery residents, and the number of applications for transplant surgery fellowship has been decreasing in recent years 1,2. The reasons for this are felt to be multifactorial. Fewer students rotate on transplant surgery with the new curriculums mixing clinical care with educational lectures, and some students may not even be at a center with transplant surgery.   Also, students can now match directly into surgical subspecialty residencies thus bypassing the opportunity to “recruit” general surgery residents to the field. Some general surgery residency programs see the “service-education” balance fall too heavily towards service and have reduced the resident time on transplant rotations. NPs and PAs are utilized to organize the complex care required of transplant patients both in- and out-patient.  For trainees there are work-life balance concerns 3 as well as questions about available jobs after training 4. Innovations in transplant surgery such as normothermic perfusion and organ procurement centers may improve the transplant operative schedule and address surgeon burnout 5. Still, it should be a priority of us as transplant surgeons to recruit highly qualified, excellent future surgeons to be our partners and eventual replacements!

To recruit an ongoing stream of future transplant surgeons, Dorry Segev, MD, PhD and Jean Emond, MD organized the ASTS Pipeline Taskforce. Our Taskforce is working to reach students and residents very early in their career to improve their exposure to transplantation. We have developed the Pipeline Award to recognize surgeons committed to sharing their love of the field and are conducting research to better understand career choices by general surgery residents. We are partnering with the Behind the Knife podcast to provide listeners with pertinent clinical information about solid organ transplantation. Listeners also have the opportunity to hear 13 diverse transplant surgeons share about both their career and life outside the hospital.

Behind The Knife/ASTS Podcast Series

Access the Podcast at: http://behindtheknife.libsyn.com/. The BTK/ASTS Miniseries was published in October 2019, but the podcasts are still available. Please promote among students and residents by encouraging them to listen to high-yield transplant information for the ABSITE and Boards.

Behind The Knife/ASTS Podcast Miniseries Session Guide


Session 1

We explore a vascular access case and the pre-transplant evaluation for both liver and kidney transplant. We also explore the most common indications for transplantation.

Dr. Arika Hoffman, a kidney transplant and vascular access surgeon, talks about her practice at University of Nebraska medical center. She also shares about balancing life with her kids with her busy clinical schedule.

Dr. Vincent Casingal is Chief of the Division of Abdominal Transplant and the surgical director of the kidney transplant program at Atrium Health’s Carolinas Medical Center in Charlotte, North Carolina. He talks about life as a transplant surgeon without a transplant fellow.

Session 2
In this session we explore what to look for when patients are called in for the liver or kidney transplant operation. The induction immunosuppression medications and their mechanisms of action are discussed.

Dr. Joshua Mezrich, transplant surgeon at the University of Wisconsin Hospital and author of recently published book, When Death Becomes Life, shares about memorable patients and what drew him to transplant surgery.

Dr. Majella Doyle is a Professor of Surgery at Washington University in St. Louis where her practice includes pediatric liver transplant surgery, adult liver/pancreas/kidney transplants, HPB surgery, and living donor nephrectomies.  She was born and trained in Ireland and discusses advice for young residents interested in a career in transplant surgery.

Session 3
This session highlights some of the most common post-transplant complications that residents and students caring for liver and kidney transplant patients may encounter.

Dr. Lisa McElroy just completed her fellowship at University of Michigan Summer 2019 and is now on faculty at Duke. She discusses finding a job and the transition from fellowship to practice.

Dr. Adeel Khan had a circuitous route to his current position at Washington University in St. Louis due to visa issues.  He gives advice to others interested in transplant surgery who may also encounter difficulty with their visas. He is busy building his robotic HPB practice in addition to his job as a multi-organ transplant surgeon.

Session 4
Session 4 examines long-term outcomes after transplant and immunosuppression medications. Also, we discuss post-transplant complications including infection, PTLD and rejection.

Dr. Satish Nadig works at the Medical Un South Carolina and is an NIH funded basic science researcher who shares his advice for future transplant surgeons.

Dr.Daniela Ladner is an Associate Professor of Surgery at Northwestern University where she Director of the Northwestern University Transplant Outcomes Research Collaborative. She is an R01 funded health services researcher.

Session 5
This unique episode discusses organ donation – both living and deceased donors.

Dr. Robert Montgomery is the director of the NYU Langone Transplant Center. He was a recipient of an HCV+ heart transplant and discusses his own experience as a patient and the research opportunities for future transplant surgeons.

Dr. Charles Rickert is a PGY-4 general surgery resident at MGH. He is currently applying for solid organ transplant fellowships after having completed his research time studying immunology and zenotransplant. He was a non-designated altruistic living kidney donor during medical school.

Session 6
In this transplant “Grab Bag” session we talk with transplant surgeons about the intersection of transplant and global/international surgery as well as transplant surgery and medical student/resident education. We also hear about multivisceral organ transplant and uterine transplant.

Dr. Jeffrey Punch at University of Michigan started the living donor kidney transplant program in Ethiopia.

Dr. Peter Liou is a resident at Columbia where he is pursuing a career in multivisceral organ transplantation.

Dr. Liza Johannesson at Baylor in Dallas, Texas shares about her experiences as a Uterine transplant surgeon.

ASTS Pipeline Taskforce members:
Dorry Segev, MD, PhD; Kelly Collins, MD; Leigh Anne Dageforde, MD, MPH; Mike Englesbe, MD; Jacqueline Garonzik Wang, MD, PhD; Jaime Glorioso, MD; Cutler Quillin, MD; Amit Tevar, MD; Anthony Watkins, MD

References

1. Quillin RC, Cortez A, Bongu A, et al. The Transplant Surgery Pipeline. ASTS Winter Symposium. https://onlinelibrary-wiley-com.ezp-prod1.hul.harvard.edu/doi/epdf/10.1111/ajt.14572.

2. Schlottmann F, Gerber DA, Patti MG. International medical graduates and unfilled positions in abdominal transplant surgery fellowships in the United States. Transpl Int. 2018;31(5):566-567. doi:10.1111/tri.13120.

3. Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568. doi:10.1097/SLA.0b013e318230097e.

4. Reich DJ, Magee JC, Gifford K, et al. Transplant surgery fellow perceptions about training and the ensuing job market-are the right number of surgeons being trained? Am J Transplant. 2011;11(2):253-260. doi:10.1111/j.1600-6143.2010.03308.x.

5. Lindemann J, Dageforde LA, Brockmeier D, et al. Organ procurement center allows for daytime liver transplantation with less resource utilization: May address burnout, pipeline, and safety for field of transplantation. Am J Transplant. 2018;11(4):1109. doi:10.1111/ajt.15129.

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