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as published in the American Journal of Surgery (01/07)
Hilary Sanfey MB, FACS, FRCSI To become a Transplant Surgeon, it is necessary to first complete a Residency in General Surgery, followed by a Fellowship in Solid Organ Transplantation. General Surgery Residency Many Transplant Surgeons first develop an interest in transplantation while training in General Surgery; therefore, the choice of a Residency for General Surgery may already have been made with other considerations or priorities in mind. However, if a student has already decided on a career in transplantation while still in medical school and before applying for a General Surgery Residency, the choice of a Residency Program may become more relevant. If this is the case, during the interview process applicants should look for a General Surgery Residency that offers -- in addition to a good broad-based training in General Surgery -- research experience in an area relevant to transplantation; for example, Immunology or Infectious Disease as well as exposure to Clinical Transplantation and Critical Care. The best information in this regard can often be obtained from other Residents in a particular institution, or from the NRMP www.nrmp.aamc.org.1 The AWS Resource Manual is a useful tool to identify members in other institutions by specialty. In assessing the potential transplant experience available to a Resident, applicants should take into consideration the number of cases performed annually, the number of fellows and upper-level Residents on the Transplant Service, and the number of operative cases. The largest Transplant Programs may not necessarily offer the best experience to Residents because of an overabundance of Fellows. Also important is to pay attention to the national reputation and mentoring skills of the Transplant Program Director, as his/her recommendations will be important to securing a Fellowship position upon completion of General Surgery training. A formal match process was initiated in 2005.1,2 The application and interview process for Fellowship training should take place during the fourth clinical year of Residency. Match results are announced in August of the fifth clinical year. Although research experience is not required, many applicants have had some formal experience during their Residency for a one- to two-year period. Most others have at least written a clinical paper or Case Reports that demonstrate some objective interest in Transplant Surgery or a related topic. Some research opportunities are discussed below. Transplant Fellowship The aim of a Transplant Surgery Fellowship Training Program is to develop proficiency in the surgical and medical management of patients with end-stage organ disease. Candidates for such training must have completed a Residency that satisfies the educational requirements for Certification by the American Board of Surgery or The American Board of Urology. A list of accredited programs is available from the Association of Transplant Surgeons (ASTS, http://www.asts.org/fellowshiptraining.cfm).2 More than 50 approved programs for Solid Organ Transplantation exist in the USA, but only approximately 20 of these are approved for all abdominal organs (liver, kidney, pancreas). The length of the program is usually two years for training in liver, kidney, and pancreas transplantation and programs accept one to two trainees per year. Applications should be made directly to the individual Transplant Program Director as soon as possible. Whereas some Transplant Surgeons later choose to specialize in one organ, it is better to train in a program that offers experience in all three areas. The program also should provide instruction in histocompatibility/immunology, infectious disease, and pre- and postoperative management of patients who require transplantation, as well as in performance and interpretation of special diagnostic techniques necessary for management of rejection and other problems in transplant recipients. Activity of the Training Program must be sufficient to ensure adequate exposure to the surgical procedures relevant to transplantation. To qualify for accreditation by the ASTS, a Transplant Surgery Fellowship Program must have 75 patients available for each Transplant Fellow to serve as the Principal Surgeon over the course of their training. In addition, for accreditation as kidney, liver, and pancreas Transplant Training Programs, each Transplant Fellow must perform at least 30 kidney transplants, 45 liver transplants, and 15 pancreas transplants over the course of their Fellowship. At least 25 multi-organ procurements should be performed annually. The length of the Fellowship period should be no less than 24 months. Programs that offer training in kidney-only or liver-only transplantation should offer at least 12 months of clinical training, with the balance of the two-year Fellowship spent in additional clinical or laboratory work. Programs that offer training in both renal and extra-renal transplantation, including multi-organ procurement, should offer at least 18 months of clinical training, with the balance of the two-year Fellowship spent in additional clinical work or laboratory experience. The Fellow also must gain experience in evaluation of living donors, as well as procurement and preservation of organs obtained from cadaver donors. The trainee also must have continuity of experience in the postoperative and long-term follow up of transplant recipients. Finally, participation in basic science research or clinical research is strongly encouraged. Board Certification No Board Certification is available in Transplant Surgery, but ASTS accreditation is required. ASTS accreditation is available upon completion of an ASTS-approved program after the individual has been in practice as a Transplant Surgeon for a year. Currently, no formal re-certification requirements are necessary for Transplant Surgery. However, transplant surgeons are expected to keep their general surgery certification current. Grant Funding and Research Fellowships A number of awards are available through industry and societies. Local, regional and national societies (see Membership section) may offer more opportunities. The following are some potential sources of funding: Medical Students Medical Students interested in Transplant Surgery should try to identify a mentor early in their careers. For students interested in a formal research experience, there may be institutional or departmental funds to support a research project. Residents Again, it is important to identify a mentor in the Transplant community as early as possible. The mentor should assist with introduction to relevant societies, choice of Fellowship programs, research projects, and letters of recommendation. Often there is a good opportunity for research at the Resident’s institution. Other possibilities for additional funding are:
Transplant Fellow Usually a Program Director will have some projects already fully funded and suitable for a short period of research.
Faculty Individual institutions may offer research funding for junior faculty as part of a recruitment package. This information is generally available from the Department Chair or Dean of the Medical School.
Membership in Transplant Societies Local and regional Transplant Surgery Societies offer open membership and provide opportunities for education or networking. The local Organ Procurement Organization (OPO, http://www.aopo.org/aopo/)3 is often a good place to begin. Several national societies are listed below under references. Full membership details are available on their Web pages. Membership criteria vary by organization, but almost anyone can attend the annual clinical meetings. ASTS (American Society Of Transplant Surgeons) Membership is open to Surgeons, Physicians, and Non-Physician Scientists actively engaged in transplantation. Full membership requires certification by American Boards and training in an approved program. In certain instances, upon recommendation of the Membership Committee with the approval of the Council, membership may be granted for equivalent experience. Surgeon members should have current active involvement as a Staff Member of a Clinical Transplant Team for at least six months, and the applicant should have a minimum of three publications in peer-reviewed journals in the field of Transplantation or Immunology to include primary authorship of at least one article. Members must make available, if requested, their patient records to a review body of the Society for ethical reasons. Other categories of membership are available for trainees, and anyone interested in transplantation can attend the Annual Meetings. References
1. National Resident Matching Program 2. American
Society Transplant Surgeons (ASTS) 3.
Association of Organ Procurement Organizations (AOPO) 4.
International Liver Transplantation Society (ILTS) 5. American
Association for the Study of Liver Disease (AASLD)
6.
Surgical Infection Society (SIS)
7. American Society
of Transplantation (AST
formerly ASTP)
8.
United Network for Organ Sharing (UNOS)
9. National
Kidney Foundation (NKF)
10.
International Pancreas Transplant Registry (IPTR)
11.
International Islet Transplant Registry (ITR)
North American Office:
12.
The Cell Transplant Society |
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