During the 25 years I’ve been a transplant doctor, I’ve cared for hundreds of patients who received lung transplants. I’m now worried about the growing number of people who will need this lifesaving procedure in the future but who won’t have enough transplant physicians to do it.
At any given time in the U.S., about 120,000 people are waiting for the call that they’ve been matched with a donor for a new lung, heart, liver, or kidney. That number will continue to rise, but the number of doctors to take the 2 a.m. call that a donor has been found for their patient and perform the transplant is dwindling.
About eight years ago, while directing the lung transplant program at Stanford University, I began noticing a sharp decrease in the number of applicants for the transplant fellowship program — a requirement to become a transplant physician — even though we had the oldest and best-established lung transplant training program in the world. Typically, I’d see five to six applicants a year, but in recent years I haven’t seen any. In my current role as a consultant to major transplant centers around the country, I’ve learned that this wasn’t specific to Stanford, and there has been a noticeable decline in the number of physicians committing to the transplant field, regardless of organ type.
Most Americans probably aren’t aware of the decline in the number of individuals training to become transplant physicians and how it will affect the future of medicine. Neither are the 2020 presidential hopefuls, all of whom have policies they believe best provide health care coverage for Americans without acknowledging or calling attention to the fact that soon there may not be enough doctors to do the work once more people are insured. We need a plan for that.
Our most vexing challenges in medicine right now are twofold: attracting young people to the field and keeping them there. These challenges are even more acute in transplantation. I have 12 months to teach fellows to be proficient at organ transplantation. It’s not enough time, so I work them hard. Throughout the history of medicine, training has been characterized as a “grand bargain” in which trainees make personal sacrifices with the expectation of a better life once they are practicing physicians. But that’s a deal many don’t accept anymore.
Physician wellness is a major factor. Up to half of physicians experience anxiety, depression, insomnia, and poor interpersonal relationships. Things may be worse for transplant physicians, as many view this field as unstructured with few boundaries to the physical work and, more importantly, one that requires a huge emotional commitment. In essence, transplantation is seen as a sure path to physician un-wellness. So, while many think about training in the field, most ultimately pursue other options.
Many experienced doctors at some of the best programs in the country are retiring a lot earlier than the traditional retirement age of 65, largely because of physician burnout. This doesn’t bode well for the field or its patients. Transplant medicine is getting harder, not easier.
Fifteen years ago, a lung transplant center would be considered large if it performed 40 transplants a year. Now the largest centers perform nearly 100 lung transplants a year (sometimes more) without concomitant increases in staffing. Harried transplant physicians care for an increasing number of patients, all the while under pressure from hospital administrators to do more transplants and pressure from regulatory bodies and insurance companies to produce better outcomes.
As transplant survival rates continue to increase, the No. 1 issue that major transplant centers now face is a shortage of properly trained physicians to both perform transplants and care for the growing number of patients with complex problems who need their doctors 24/7. Caring for them requires a degree of comfort with the unknown. Yet younger physicians seem less comfortable with medical uncertainty than older physicians. They’re more content with defined treatment plans that are often anathema to the practice of organ transplantation. They also have more options for well-paying jobs, controllable hours, and easier patients to care for.
To entice young physicians to become part of such an important field, we need to use technology, where possible, to unburden the transplant team. One area of focus should be the organ procurement process, which is a logistical nightmare — flying from one city to another to retrieve organs from a distant hospital — costly, and requires staffing that most transplant programs don’t have. Surgeons who are flying around the country in the middle of the night to procure organs often have complex surgeries scheduled the following day. Various technologies to keep organs “alive” until the transplant exist, but haven’t been adopted by enough transplant centers due to inertia, resistance to change, and the cost of investing in these new technologies.
Transplant programs also need to implement better care models by including mid-level practitioners like physician assistants and nurse practitioners. They can provide patients with continuity of care — a familiar face who will be around long after the trainees are gone. These practitioners can execute protocols and take on significant roles in overall patient care instead of relying on the physician trainees who currently provide the majority of care.
That may not be the transplant field I trained to be part of, but it is what we need to ensure that the next generation of transplant physicians will be there to save the lives of people whose organs are failing.
In the past 25 years, I never once had to question if my job had meaning. It is my mission to make sure transplant trainees won’t question theirs either.
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