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Abstract

  1. Top of page
  2. Abstract
  3. Has Transplantation Lost Its Luster?
  4. References
  5. The Next Generation in Europe
  6. References

Has transplantation, once the innovative darling of medicine, lost its novelty for young surgeons and physicians?“The AJT Report” takes a look at the shortage of trainees in transplant medicine and surgery and possible ways to solve the problem. Also this month, new OPTN/UNOS officers and board members take their posts.


Has Transplantation Lost Its Luster?

  1. Top of page
  2. Abstract
  3. Has Transplantation Lost Its Luster?
  4. References
  5. The Next Generation in Europe
  6. References

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On June 22, the U.S. National Resident Matching Program will announce 2012 matches for Abdominal Transplant Surgery Fellowships. If the trend of recent years continues, one-quarter or more of those positions will go unfilled. While the match is only one indicator of interest in transplantation as a career, transplant leaders say there is also a drop in trainees for medical transplant care and in surgery for cardiothoracic and less-performed transplants, such as intestine.

Is it that transplantation, once the innovative darling of medicine, has lost its novelty for young surgeons and physicians? That's what one fellow told Michael Abecassis, MD, chief of Northwestern University's Division of Organ Transplantation in Chicago, and president of the American Society of Transplant Surgeons (ASTS). Six months before his starting date the fellow backed out, saying, “Transplant has lost its luster.”

The following year at Northwestern, another fellow backed out one month before his starting date and, this year, a fellow quit the first day on the job. Both indicated their interest in transplant had “dwindled.” Dr. Abecassis doesn't know whether other programs have had this experience, but says, “We can't be unique.”

John Lake, MD, director of the Liver Transplant Program at the University of Minnesota in Minneapolis, and incoming president of the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) board of directors, says most transplant surgery has become “pretty routine.” When Maryl Johnson, MD, medical director of the Heart Failure and Cardiac Transplant Program at the University of Wisconsin, Madison, and president of the American Society of Transplantation (AST) first became involved in transplantation, “every heart transplant made the newspaper. That just isn't the case anymore.”

And, it doesn't help if doctors in training see that their role models are unhappy about long work hours or lower reimbursement compared with colleagues in other specialties.

Reasons for the Decline

There are many reasons why the specialty is seeing a decline in new trainees:

1. An Extremely Tight Job Market

Leaders in the field are still in practice, and new job openings are limited by the shortage of donor organs, leaving centers in a struggle to keep up their transplant numbers. Medical students know this. “Five years ago, you never heard of any problem finding jobs,” says Dr. Lake. Dr. Abecassis adds that he wouldn't be surprised if “half the fellows finishing this year won't end up with a good job in the United States. We went through this about 10 to 12 years ago, and then the market opened up, largely due to living donors. However, I think that's plateauing now.”

KEY POINTS

  • • 
    As transplant procedures become more routine and innovation gives way somewhat to service delivery, the fields of transplant medicine and surgery are experiencing a change in number and type of trainees. I
  • • 
    A tight job market, a stressful lifestyle, regulation and reimbursement policies, and low funding in the field are all contributing to the decline. I
  • • 
    The job market is ultimately capitated by the number of donors.

2. Lifestyle

In recent years, there's been a significant shift toward specialties with easier lifestyles. Transplant is one of the surgical specialties where the goal of an 80-hour week is frequently exceeded by both fellows and faculty, with unpredictable hours and high stress. Perhaps due to these lifestyle issues, there's been a drop in general surgery applicants in the past five to six years. “If you decrease the pipeline, you decrease [the number of] people going into transplantation,” says Dr. Abecassis.

3. A Highly Regulated Field

One problem with regulations is that they are an attempt to make everything uniform, says Richard B. Freeman, Jr., chair of the Department of Surgery at Dartmouth-Hitchcock Medical Center, Lebanon, N.H. “As a result, you’re stifling innovation. It's our obligation to convince the regulatory authorities that you need mechanisms to take risks and not lose your shirt if you do and you’re wrong.” Dr. Abecassis agrees: “The fact that you could make something on the fly and feel good about it…that innovation made transplantation really cool. Now it's so regulated, you’re afraid to innovate.”

4. Reimbursement

For physicians in transplant clinical care, reimbursement is lower (due to relative value units) than in specialties with numerous procedures, says Dr. Johnson. “People interested in the field know this; they hear their colleagues talking about it.” Dr. Freeman agrees, noting that the ability to make a significant salary is becoming diminished.

5. Funding for Trainees

One of the problems in kidney, heart and lung transplantation is that there are no Accreditation Council for Graduate Medical Education (ACGME)-approved transplant medicine fellowships. “There are kidney programs approved by the AST, but they do not lead to board certification,” says Dr. Lake. “Thus, you can't use ACGME funds to pay for the additional year of training.” According to Allan Kirk, MD, professor of surgery at Emory University in Atlanta and AJT editor in chief, “This also limits the role these fellowships play in allowing foreign medical graduates entry into the U.S. job market. Many states require ACGME-approved training as a prerequisite for licensure. Thus, surgeons remain ineligible for licensure in some states if their only U.S. training is a transplant fellowship.”

6. Lack of Research Funding

As noted in a recent issue of AJT, the number of transplant surgeons establishing rigorous research careers is low, likely due to a dramatic decrease in National Institutes of Health funding.1“Typically, people who went into transplant tended to be academically inclined—basic research, immunobiology-type people,” says Dr. Abecassis. “Now they realize they aren't going to get funding.” For the field of transplantation to move forward, says Dr. Johnson, there needs to be more than people to take care of patients. “Those involved in the basic science of developing the concept as well as the translation of that science to the clinical arena,” are needed, says Dr. Johnson.

What Can We Do About It?

As for the training programs themselves, John Magee, MD, University of Michigan, Ann Arbor, transplant surgeon and past chair of the ASTS Fellowship Committee, says the society has developed a curriculum to formalize the core of knowledge fellows should master, and it continues to refine accreditation standards to make fellowship training as responsible as possible. However, “we could do a better job illustrating, as well as structuring, a future that allows more work/life balance,” he says. “We have tried to figure this out and determine the factors, but it's still a work in progress.”

It may come down to finding new ways to use donors and increase the number of surgeries. “I don't think we’re going to get the government off our back in the short term,” says Dr. Freeman. Dr. Johnson suggests initiating earlier discussions among prospective students. “Perhaps we can talk to them at the undergraduate level or, for basic sciences, early in their graduate training.”

However, a shift in the way the field is structured may be in order. “We need to change the paradigm,” says Dr. Abecassis. “That can take a lot of forms. One way is to get away from the cookie-cutter model of transplant surgery, saying that everybody has to be a triple threat—a surgeon, clinician and researcher. We need to create new molds, and that's going to take some thinking.” He would like to see ASTS take the lead by including emerging technologies and bringing in disparate disciplines such as biomedical engineers, material scientists and tissue engineering experts. “For 50 years, the holy grail has been immune tolerance. I think we have to redefine the holy grail; for example, to something such as an artificial organ that doesn't need immunosuppression. That's reinventing yourself!”

And perhaps it's time. “Guys like Starzl, Murray, Calne and Shumway teed it up for us,” says Dr. Abecassis. “We’ve had 30 years riding on their shoulders. Now it's time for us to tee it up for the next generation. It's time to put the luster back on transplantation.”

Dr. Kirk agrees. “Ultimately the most important advertisement for a career in transplantation is an enthusiastic mentor,” he says. “Transplantation remains at its core an exceptionally rewarding and stimulating career path. We need to show that to the medical students and residents with whom we interact, and be careful not to over-emphasize the day-to-day administrative strife inherent in any medical practice to the point of obscuring the innate wonder we all share for our work.”

References

  1. Top of page
  2. Abstract
  3. Has Transplantation Lost Its Luster?
  4. References
  5. The Next Generation in Europe
  6. References

The Next Generation in Europe

  1. Top of page
  2. Abstract
  3. Has Transplantation Lost Its Luster?
  4. References
  5. The Next Generation in Europe
  6. References

Is there a declining interest in transplantation as a career in Europe? Ewen Harrison, MB, ChB, PhD, who represents the European Society for Organ Transplantation (ESOT), isn't aware of hard data, but says the Organization for Economic Co-Operation and Development (OECD) report a trend of increasing numbers of doctors per capita across Europe over the last 15 years except for a recent reversal of that trend in Italy and France. He adds, “It would be our feeling that there has been a commensurate increase in the number of transplantation physicians and surgeons in line with this.”

Dr. Harrison notes that a public debate in the U.K. in 2004 highlighted a “crisis” in the recruitment of transplant surgeons.1“It was suggested that transplantation surgery had an ‘image problem,’ with a reputation for excessive unsociable working hours and relatively poor financial remuneration. That perception persists, but the number of unfilled posts has decreased since that time.”

James Neuberger, MA, BM, BCh, DM, associate medical director of National Health Service (NHS) Blood and Transplant in the U.K., says that “the introduction of the National Organ Retrieval Service, which covers all four nations of the U.K., has recruited many young surgeons who will be attached to transplant units.” However, “there is concern about the number of skilled transplant surgeons, especially in cardiothoracic transplantation. For medicine, there is no shortage as far as I am aware.”

Regarding lifestyle challenges, Dr. Neuberger says, “I think transplantation is very demanding, but also rewarding. So most clinicians, once bitten, stay infected. I certainly have no regrets.”

References

  1. Top of page
  2. Abstract
  3. Has Transplantation Lost Its Luster?
  4. References
  5. The Next Generation in Europe
  6. References