Transplant Surgery

[MS05']

I have a few questions regarding transplant surgery I was hoping someone could answer.

More or less I was wondering if one does a transplant fellowship are you limited to doing academic surgery or can the transplant guys do more of a community general surgeon who does transplants occasionally type of thing?

What's the lifestyle like?

After the fellowship I understand that you can do liver, kidneys and pancreas, but was wondering if this was limited to adults? For example, would one need to do a pediatric fellowship too if you wanted to do renal transplants on kids?

Thanks in advance!

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[Winged Scapula]

I have a few questions regarding transplant surgery I was hoping someone could answer.

More or less I was wondering if one does a transplant fellowship are you limited to doing academic surgery or can the transplant guys do more of a community general surgeon who does transplants occasionally type of thing?

What's the lifestyle like?

After the fellowship I understand that you can do liver, kidneys and pancreas, but was wondering if this was limited to adults? For example, would one need to do a pediatric fellowship too if you wanted to do renal transplants on kids?

Thanks in advance!

You do not need to do a Pediatric surgery fellowship to do pediatric transplants - you will be trained sufficiently in your Transplant fellowship.

Most Transplant surgeons work in the academic environment because Transplant patients require a large interdisciplinary team with good critical care availability. I suppose you could be a "community guy who does transplants occasionally" but frankly I wouldn't want a transplant from that guy - the work is pretty technical and you wouldn't want to get rusty. You want nurses and other allied health people who are used to working with transplant patients before, during and after transplantations as these patients tend to be frequent flyers.

The lifestyle is unpredictable - organs often become available in the middle of the night, on holidays, etc. Of course, you can refuse to accept the organ if you find this inconvenient but you have chosen a field which lends itself to unpredictability and you have an obligation to your patients, IMHO. When organs aren't available or your patients aren't good matches, you spend you time caring for those in house with possible rejections, doing biopsies, general surgery cases, research, etc. So you can have some free time available but you'll never know what will happen those nights you're on call even as an attending...our interns hate it because there are always potential admits for transplant work up which involves a lot of paper work for them.

 

[doc05]

can the transplant guys do more of a community general surgeon who does transplants occasionally type of thing?

if you needed a new kidney, would you go to someone who "does transplants occasionally?" Question asked, question answered.

 

[MS05']

if you needed a new kidney, would you go to someone who "does transplants occasionally?" Question asked, question answered.

No I wouldn't, but I can't count the amount of times I've seen it happen. Mostly by laproscopic fellowship trained surgeons. Thanks for the information and the constructive post doc05, you're a real asset to the SDN list serve.

 

[Winged Scapula]

No I wouldn't, but I can't count the amount of times I've seen it happen. Mostly by laproscopic fellowship trained surgeons. Thanks for the information and the constructive post doc05, you're a real asset to the SDN list serve.

Really? Hmmm...we have our laparoscopic surgeons remove donor organs (or other organs, ie, spleens) on occassion but I've never seen anyone other than a Transplant surgeon actually transplant the organ.

 

[MS05']

Really? Hmmm...we have our laparoscopic surgeons remove donor organs (or other organs, ie, spleens) on occassion but I've never seen anyone other than a Transplant surgeon actually transplant the organ.

There is a collobrative team here where the laproscopic and urologic and gen surg people do the renal transplants. Didn't assume this was the standard. I've only seen this done with renal tx, never with liver or pancreas though. I don't know if it's due to a lack of transplant surgeons in WNY or if the above three feels as though working together is just as good.

 

[johnny_blaze]

Hmmm I have a thought… Would a GS fellowship trained hepatobiliary and pancreatic surgeon be able to do liver/panc transplants? I could have sworn I read somewhere that they can (or are trained to).

 

[Winged Scapula]

There is a collobrative team here where the laproscopic and urologic and gen surg people do the renal transplants. Didn't assume this was the standard. I've only seen this done with renal tx, never with liver or pancreas though. I don't know if it's due to a lack of transplant surgeons in WNY or if the above three feels as though working together is just as good.

Interesting...thanks for the info.

 

[TransplantSurg]

I have a few questions regarding transplant surgery I was hoping someone could answer.

More or less I was wondering if one does a transplant fellowship are you limited to doing academic surgery or can the transplant guys do more of a community general surgeon who does transplants occasionally type of thing?

What's the lifestyle like?

After the fellowship I understand that you can do liver, kidneys and pancreas, but was wondering if this was limited to adults? For example, would one need to do a pediatric fellowship too if you wanted to do renal transplants on kids?

Thanks in advance!

A few answers that may help:

There has been somewhat of a trend for surgeons wanting to do pediatric transplant surgery to do pediatric surgery fellowships and transplant fellowships. Since there are very few pediatric transplant surgeons needed this then allows you to do txs but also these surgeons will often do hepatobiliary surgery on kids as well - i.e. Kasai for biliary atresia - different places are set up differently.

Training as tx surgeon also trains you in small bowel and multi visceral. As for kidney - those are usually done by someone who specializes in kidney and at some places is done by Urology trained surgeons. lifestyle - I agree with previous statement with one addition - transplant is not yet a certified board specialty and thus the number of fellowship trained surgeons is not tightly regulated and yet the number of organs is not increasing, thus, going into this field could mean a decent amount of down time in between cases (though becoming less so with living donor options and hopefully xenotransplant on the horizon) at least on the pediatric side and more trained surgeons than available jobs. All that being said I obviously think it is a great and exciting field!

 

[Bo Hurley]

Don't even think about going into Tx surg if you want any semblence of a "normal" life. Surgery is bad enough in that regard, it is only worse in Tx surgery. I've seen 50 year old attendings pull long, unpredictable shifts only to do their scheduled GS cases the next morning. IMHO, Tx surgery has the worst hours of any specialty out there.

 

[MS05']

Interesting...thanks for the info.

No problem.



Hmmm, didn't realize the lifestyle was so crappy. Is this reflected in the salary or the off time? I mean, like critical care, can you be onservice for transplants and gen surgery for 8-10 months and then off 2 months for research?

 

[surg]

I hate to say it, because it's a truism. You can have any practice style that you want, it just depends on what you are willing to sacrifice to get it.

There are some surgeons outside of the bigger academic centers who do kidneys, I am not aware of any that do livers. They are transplant trained and also do some general surgery and generally operate at community teaching hospitals. You can find listings of all transplant centers
at http://www.ustransplant.org/csr_0105/index.php

Still, the biggest job opportunities at at academic centers that you would at least recognize their names even if they didn't spring to mind as a "big-time" center. They are spread out all over the country.

Research and scheduling is determined by your group both in size and composition. Academics tend to negotiate for some research time off either by days of the week, weeks of the month, or months of the year. However, the ability to do this is decreasing as academic centers rely more heavily on their clinical revenues than ever before. The size of your group probably matter more. The reason I say this is that every center has a waitlist. As a transplant surgeon you generally get a call from the OPO (organ procurement organization) coordinator with an offer of an organ from a non-living donor and you can say yes or no. You can give basically any reason for saying no, but in the back of your mind you know this patient who is waiting for the organ and it is difficult to say no if the offered organ is a good one. A big group is able to rotate the call in such a way that you don't have to be on organ call all the time.

Finally, WHAT organs you choose to make part of your transplant practice makes a difference. If you only do kidneys (which many people do if they aren't in a big center. Some fellowships only train you to do kidneys. http://www.asts.org/fellowshiptraining.cfm ) your life is actually pretty good. Most kidney will last a long time on ice and you can schedule them for a time that is somewhat convenient for you (i.e. not at 2AM). The operation takes about 2-3 hrs from lines in to skin closed. Many can be scheduled because there are living donors willing to donate. Most receipients leave the hospital within 3 days. If you do pancreas and liver then you are working against the clock a little more, as they don't last as long on ice and they stay in the hospital a lot longer.

Pay averages a lot better than general surgeons as a rule since the operations pay better and the donor operations pay really well (they are cash-pay via the OPO). Last time I looked in the AAMC book I seem to remember about a 30-40% premium for transplant surgeons on average level for level (e.g. assistant prof to assistant prof.) as compared to general surgery.

I hope that helps.

 

[The_Id]

No problem.



Hmmm, didn't realize the lifestyle was so crappy. Is this reflected in the salary or the off time? I mean, like critical care, can you be onservice for transplants and gen surgery for 8-10 months and then off 2 months for research?

If you are at an academic institution, you can definitely have dedicated time off because research is often a critical aspect of being a transplant surgeon. For example, at Yale, there are 3 transplant surgeons who have three one-week rotations:

Week one: you are the ward attending for all transplant patients, take ER call for transplant patients, and are first-called for any transplant surgeries. This is obviously a very busy week.

Week two: you are second-called for any transplant surgeries. Therefore, you are mainly called in only for scheduled for kidney transplants from living donors. The rest of the time is spent in lab.

Week three: you have dedicated research time, and don't do any transplant emergencies. This week is very easy.

* No matter which rotation you are on, you still have to be at clinic one or two days per week to see your transplant patients.

I would assume things are run similarly at places where there is a group of transplant surgeons. Not too bad, actually, if you can get this sort of arrangement.

 

[Treg]

If you are at an academic institution, you can definitely have dedicated time off because research is often a critical aspect of being a transplant surgeon. For example, at Yale, there are 3 transplant surgeons who have three one-week rotations:

Week one: you are the ward attending for all transplant patients, take ER call for transplant patients, and are first-called for any transplant surgeries. This is obviously a very busy week.

Week two: you are second-called for any transplant surgeries. Therefore, you are mainly called in only for scheduled for kidney transplants from living donors. The rest of the time is spent in lab.

Week three: you have dedicated research time, and don't do any transplant emergencies. This week is very easy.

* No matter which rotation you are on, you still have to be at clinic one or two days per week to see your transplant patients.

I would assume things are run similarly at places where there is a group of transplant surgeons. Not too bad, actually, if you can get this sort of arrangement.

This is exactly how it is at our center. The call is 1 in 3, but they usually do a block of 7-10 days in a row. They also have ~1 day/week of elective time for hepatobiliary cases, and clinic 1-2 half days/week. The living-donor cases are considered elective and as such are scheduled, here for livers it is one day/month on average. Also, if there is a cadaveric donor, the elective cases get bumped. Second on call is for pancreas or SPK transplants. We have two transplant fellows that are either on call for the donor or the recip, so they are on call all the time. The attendings rarely go for donors, that is all left to the fellows, which can be a lot of work since our center covers a huge geographical area. All of the attendings have active research labs which are generally run on a day to day basis by RAs.

The lifestyle really isn't that bad. The attendings are really busy on a day to day basis, of course. But during the call week, they might do 2-4 transplants, usually starting around 6-10 in the morning. I have gone to a lot of transplants, and only once did we do one in the middle of the night, and that was for a 21 yo status 1 in fulminant liver failure, comatose. The attendings here also do all of the peds transplant cases, at least for liver.

I have also heard many times from the fellows that it is difficult to find a job right now, and that you had better be a seasoned researcher to even be considered.

Treg

 

[mayostand]

What's the general feel out there as far as how difficult it is to get a transplant fellowship? I wouldn't think it would be as tough as peds, but not the easiest one to get into either. Any lists of applicants/spots?

 

[Winged Scapula]

What's the general feel out there as far as how difficult it is to get a transplant fellowship? I wouldn't think it would be as tough as peds, but not the easiest one to get into either. Any lists of applicants/spots?

General consensus - relatively non-competitive, much easier than Peds.

 

[SocialistMD]

Hmmm I have a thought… Would a GS fellowship trained hepatobiliary and pancreatic surgeon be able to do liver/panc transplants? I could have sworn I read somewhere that they can (or are trained to).

From what I've seen, the opposite (transplant-trained surgeons doing HPB procedures) is more the case than what you have suggested.

 

[SocialistMD]

What's the general feel out there as far as how difficult it is to get a transplant fellowship? I wouldn't think it would be as tough as peds, but not the easiest one to get into either. Any lists of applicants/spots?

I think it is one of the easiest simply because no one wants that life. Many surgeons with whom I've spoken say they enjoyed the procedures, but didn't enjoy the lifestyle enough to persue it as a career.

 

[Celiac Plexus]

besides the unpredictable schedule of transplant, the work-up and management of transplant patients is more involved than the typical lap chole patient.

you will find that there are some transplant surgeons who just do kidneys since the management, w/u, and politics are slightly less involved than say livers. but still, i agree with the peanut gallery on this one: "lifestyle" sacrifice is the highest for transplant surgeons, and that is probably why such a cool field is relatively uncompetitive.

 

[JKP]

Does anyone know if there are any transplant surgeons out there doing research on stem cell related topics?

 

[SocialistMD]

Does anyone know if there are any transplant surgeons out there doing research on stem cell related topics?

Kauffman at Northwestern is doing something of the sort with islet cells. I'm sure there are others, but he is the only one I can think of off the top of my head.

 

[doc05]

Question: Do urologists that have done fellowships in transplant surgery limit themselves to transplant surgery or do they do transplants plus urological procedures on a regular basis?

Most probably do general urology or urologic oncology in addition to kidney transplant.

It's unlikely that there would be enough transplant work to keep them consistently busy. But like most things, it depends on the specifics of the practice.