Thoughts on Transplant Surgery

Session 223

Today, we talk to Dr. David Foley, an abdominal transplant surgeon who’s been practicing for 18 years in an Academic setting. Let’s talk about their journey.

If you are interested in learning more about abdominal transplant surgery, check out the American Society of Transplant Surgeons.

For more podcast resources to help you with your medical school journey and beyond, check out Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:06] Interest in Abdominal Transplant Surgery

David initially wanted to just be a general surgeon. Eventually, he decided to go into the lab with the new chair of surgery at UMass, Dr. Bill Meyers, who became his mentor. Apparently, Dr. Meyers started the liver transplant program at Duke University and is also their chair of surgery now.

David was so impressed with how his mentor was able to conduct a human liver transplant and the patient got to live for about 12 years. And so, he started working in his lab doing some porcine pig liver perfusions and how to stimulate the liver’s function.

On the clinical side, David loves doing vascular surgery. During his general surgical residency, he loved suturing blood vessels and operating on the abdomen. A lot of vascular surgery is done on the peripheral vessels in the legs and limb salvage. Not really as interested in that, he was trying to figure out the best practice for dealing with blood vessels in the belly. And he found out that Transplant was the best fit.

[05:19] Learning the Skills and Gaining the Confidence in Operating tiny Blood Vessels

David points out that you need to have good eye-hand coordination before coming in. But you learn it when you’re there too. And as you end up doing surgery, it involves fine meticulous movements of your wrist and your fingers. There’s a way for turning your wrists so it allows you to place a needle through blood vessels.

As with David, he built up the eye-hand coordination as an athlete playing baseball and hockey. It doesn’t mean that you can’t be a great surgeon if you don’t play sports.

It potentially helps if you can do stuff with your hands early on. But you truly don’t know until you practice it so you need good mentors, good teachers, and good surgical teachers in the operating room.

[07:01] The Biggest Trait to Become a Successful Transplant Surgeon

Transplant surgery encompasses high stress. You have to have a good surgical skill set. More importantly, it’s not just the suturing challenge, but also the decision-making involved when you’re in the operating room.

'What makes a surgeon a good surgeon is the decision making, although you need the skills to execute the suturing.'Click To Tweet

David adds that Transplant Surgery is an endurance field. The fellowship is very challenging. You work a lot of hours and you’re in the operating room a lot. There are difficult cases and hard cases that you have to learn to navigate.

It’s a high-stress, yet high reward operation. Once you’re able to get through the operation, the impact you have on patients is tremendous.

It also helps to have the ability to understand that even if you make some mistakes, you just move on. He admits they all make mistakes, both in the operating room and outside the operating room. But on top of that, you have to have a good understanding of the medical side of transplants, particularly, the immunology aspect, which is what David loves the most.

At the end of the day, you have to have the medical side and the surgical side. And if you liked both sides of that, it’s one of the traits of becoming a really good transplant surgeon.

[08:58] Common Myths or Misconceptions Around Transplant Surgery

David says that Transplant Surgery is one of the hardest fellowships out there along with cardiothoracic surgery with regards to the time and the commitment that it takes. But after that, once you get into your faculty/assistant Associate Professor position, you’re still in a busy Transplant Center. You work very hard, but it gets better. It’s not like you’re always in that world of always working.

'There are opportunities to have balance and work-life balance, depending on where you work as a transplant surgeon.' Click To Tweet

And so, the myth is you never have time to yourself. It is a very unpredictable career, David explains. At any time when they get a call, they might be back in the operating room in the middle of the night.

[10:24] A Change in Their Process of Recovering Organs

David says they’re allowing other people to recover organs for them, depending on the organ. For kidneys, it’s a relatively straightforward recovery. Most centers are fine with other center surgeons recovering the kidneys that you’ll transplant at your center.

Historically, they need to get their own liver due to trust concerns. That being said, there has been a switch to not have to send their entire team to the hospital three states away. They now allow them to locally recover it, so they can just look at pictures, and talk to them in the operating room.

There are all these communication pathways they now have to see exactly what the liver looks like. And most of the time, you can just let someone else recover the liver for you. Hence, it has transitioned a lot in the midst of COVID.

[12:04] A Typical Day

As the chair of the division of Transplant Surgery in their institution, David has administrative roles as well as clinical roles. But in a week that he’s on call, he usually checks the labs on the computer of all his patients who are on service in-house. Then he rounds with the team and they establish a plan for the day. In the middle of that, he might be getting an “organ offer” call. And so, it’s very inconsistent from day to day.

They don’t do liver transplants every night. But when you get an offer, you end up doing a transplant in a 24-hour period. You’ll end up rounding and seeing patients in the clinic. And then you would go ahead and prepare for the patient to come in who’s going to get that liver transplant that night or early the next morning.

'The thing about transplant surgery is that we can't do any transplant surgery without our donors.'Click To Tweet

They also do a lot of back and forth communication with the organ procurement organization. Logistically, they are trying to schedule when the operation is going to occur, the transportation, etc. But they have people called the organ allocation specialists that can help them do that. They work at their institution and help with the logistics and the coordination.

As a transplant surgeon, he doesn’t have to do all that. But when the patient comes in, he sees the patient and makes sure they’re suitable for the transplant. They have already discussed this patient and put them on the transplant list. And it’s just to make sure they haven’t developed any infections and they’re suitable for transplant.

Then he goes home and gets some sleep. Then he might wake up at three in the morning and come back in, as he gets ready to do a five to 12-hour operation depending on how it goes.

[14:29] An Opt-Out Organ Donation System

Obviously, with organ donation, you need the donors there. And we see other countries moving toward an opt-out organ donation system. For instance, the person goes to the DMV. And instead of the DMV asking them if they want to donate their organs, the default answer is that they will donate the organ. Then they just mark it there if they choose to opt-out.

In the U.S. however, we have an opt-in system for organ donation. From a transplant surgery society standpoint, David says they know that there are thousands of patients that die on the transplant list every day. Every year, there’s a donor organ shortage.

From a utilization standpoint, David says they would love to have an opt-out program such that the patients actually would have to opt themselves out of organ donation.

That being said, this stirs up a lot of controversy in our society. A lot of patients out there in the community may not want that. David adds that we live in the United States where they want to be in control of how they would like to go about with organ donation. He is totally fine with the fact that the patients ultimately have to make their own decision on organ donation.

One of the benefits of the transplant community has been the “first-person authorization.” Historically, when you’re passing away, it would be the next of kin to decide if you could be an organ donor. But now, patients can go to the donor registry in the state and decide to opt in. And so, it’s a legally binding opt-in.

A lot of states have laws on “first-person authorization” that have substantially helped increase organ donation rates. They may not have told their loved ones before they passed away. But once they’re informed that their loved one wanted to do this and signed up as an organ donor, it’s much easier for that family to move ahead with organ donation.

[17:36] The Training Path

After four years of medical school and five to six years of general surgery residency, you do two years of a clinical transplant fellowship. Then you get a certificate of completion from the American Society of Transplant Surgery.

Right now, transplant surgeons do not have board certification. It’s not recognized as a boarded subspecialty. However, the ASTS has taken it upon themselves to generate a credentialing and certification pathway.

If anyone is in medical school and residency now, they would eventually go through this certification pathway. It entails taking the exam and then practicing for a year. They also do this in other specialties like colorectal surgery and orthopedics. Then you take a list of your cases in the first year, and you have an oral exam based on the cases.

[19:08] Overcoming the Bias Against DOs

'Everyone can apply for a transplant surgery fellowship after you graduate your general surgical residency, regardless of if you went to med school or osteopathic school.'Click To Tweet

David suggests trying to identify one or two years of research during your residency. David is also the program director at their fellowship and he says they look for people who have done dedicated research time.

There’s a broader base of training and education for someone who does five years of clinical surgery and two years of research. It allows you to become a better thinker on the floor. You’re better able to analyze patients’ conditions in a more critical way. And David personally doesn’t think he would have had that as much as had he not done two years in the lab.

Therefore, if you can, get involved in a lab and some research projects. Write a couple of papers and learn how to present at national meetings.

Academia vs. Private Practice

Learn an academic surgery pathway. David adds that you could always go into private practice surgery, if you go into academic surgery, and then go to private practice.

If you’re focused on private practice, it’s tough to get into academics because you have to do the academic stuff – research, presentations, etc. If you could learn that as a skill set during your residency with good mentorship, you’d be setting yourself up to become a great transplant surgical fellow and a transplant surgeon.

Although unsure of the specific numbers, David reckons the majority of transplant surgeons are in an academic setting. But if you want to be a kidney transplant surgeon in a private practice setting, you’re more likely to find a spot than if you want to do liver transplantation.

There are a lot of liver transplant programs that would be more academic. There are a lot of community and private practice liver transplant programs in the country as well. Ultimately, if you have the opportunity to do both, then it just keeps your doors open.

[21:51] Other Organs for Abdominal Transplants

Aside from kidney and liver, pancreas transplantation is a well-recognized standard of care for patients with Type I diabetes and kidney failure. They also do simultaneous pancreas and kidney transplants. They do pancreas transplants for patients who have gotten a kidney transplant, say, from a living donor but still have diabetes. Then they can go ahead and do a pancreas transplant after a kidney transplant so they can cure their diabetes.

The third patient population who gets a pancreas transplant is someone with unrelenting diabetes or an inability like hypoglycemic unawareness. They don’t know when their sugar’s dropping. So there’s a select number of patients that would benefit from a pancreas transplant alone.

Aside from pancreas, liver, and kidney transplants, they also do small bowel transplants at a small number of centers across the country. The patient population for this is those with short bowel syndrome. Or people who’ve had a traumatic car accident and that have had to have their bowel removed from traumatic injury. If they get through that onslaught of trauma, they could certainly be candidates for a small bowel transplant.

[23:39] What He Wished He Knew Before

David says he didn’t realize that the jobs are not as prevalent after you go through a transplant surgery fellowship.

For instance, in colorectal surgery and vascular surgery, there’s much more vascular disease and colon and rectal disease where you could pretty much go anywhere in the country. And you could likely find a position. But transplant surgery is limited by the donor as there’s a limitation in terms of the number of jobs that are out there. Just recognize that you might have to just go to other parts of the country and set up shop at another place where you can practice as a transplant surgeon.

David also adds that he now has a better appreciation of the benefit and the impact on their patients’ lives.

He says he knew he liked it for the technical aspects and knowing that patients did well. But it’s not until you’re embedded in the specialty and you see patients on death’s door with liver failure, and then you can transplant them. Then after a week, they’re a different person.

Patients on dialysis are miserable and when you get them off dialysis, they’re so happy that they’re no longer on dialysis. They’re happy they don’t have to go there three days a week.

[25:45] General Surgery Work vs. Transplant Cases

If you go to a transplant center that does a small volume of kidney transplants per year (no liver, no pancreas), you’ll probably end up doing more general surgical calls.

If two or three surgeons do 60 to 70 kidney transplants a year and nothing else, you’re probably going to end up doing more general surgery calls. If you go to a transplant program that does 100 liver transplants a year or 300 kidney transplants a year, and you’re going to be doing liver and kidney transplants, you’re probably going to be busy enough just doing transplants.

You won’t be doing a lot of general surgery, but you’ll be doing some general surgery on your transplant patients. If they come in with certain small bowel obstruction or something, you end up operating on those patients.

For the most part, it depends on how busy the center is where you get your job. So if it’s low volume, you will probably do more general surgical stuff, and if there’s higher volume, probably less.

'Coming out of a program, you really don't want to be starting your own program coming out of your fellowship.'Click To Tweet

[27:42] The Most and Least Liked Things

David likes the multidisciplinary aspect of the field. In transplant, you have to work with nephrologists, hepatologists, dieticians, social workers, and coordinators. And you have to determine whether or not someone’s a suitable candidate for transplant before you even decide to do an operation on them.

He loves having that multidisciplinary approach because you work with great people in the medical subspecialties.

“Bringing in other team members is very valuable.”Click To Tweet

On the flip side, what David likes the least about the specialty, he says, is that as you get older, there’s an uncertainty of when you’re going to be doing a transplant. When you’re hungry and you come out of fellowship, and you just want to do a lot of surgery, the uncertainty doesn’t affect you as much. You’re always not sure when you’ll be doing surgery.

In other subspecialties, you set your cases on Mondays, Wednesdays, and Thursdays. And that’s when you know you’re doing surgery. But in transplant, you do have to commit to the uncertainty. And when you’re on call, it’s tough to make plans with your family.

'There is an uncertainty to a career in transplant surgery that you don't see in other surgical subspecialties.' Click To Tweet

[30:57] What the Future Looks Like

Xenotransplantation uses pig kidneys and David says we are moving more towards being able to use pig kidneys in clinical transplantation. There are a bunch of barriers they need to get over there. They’re all immunological barriers, but he’s positive they can get there.

Additionally, the machine perfusion of organs has taken a big step over the last five years. It means that if you take out a liver, and you can perfuse it for 12 hours, you can be flexible in terms of when you’re scheduling the surgery. And you wouldn’t have to do them all in the middle of the night. They’re in the midst of clinical trials.

Other centers across the country are trying to assess the viability of a liver. They used to just preserve it with a cold preservation solution, which is the standard of care.

David adds that the wave of the future in the next five to ten years is the ex vivo or the out of the body perfusion of organs. They can resuscitate these organs and treat them with proteins or other therapies to make them work better.

They might go and recover an organ that they don’t think is suitable for transplant. But they can resuscitate them and make them better so they can do more transplants. It has a possibility of making their surgeries a little bit more elective during the day.

[33:07] Final Words of Wisdom

If he had to do it all over again, David says he would still have chosen abdominal transplant surgery. He has been doing this for 20 years and he still loves it.

Finally, to those who might be interested in this subspecialty, David recommends getting involved early. Even in medical school, if there’s time to do electives, try to do an elective at a transplant center or you can go into someone’s lab to do some transplant research. Certainly, as a surgical resident, you can also do that as well. Get involved in someone’s research and do a couple of years in the laboratory if possible.

Lastly, finding the right mentor at your institution would be key. Ask them what they think about transplant surgery. And David thinks that if you find the right role model, you’ll be addicted to it like they are. It could attract you right into the subspecialty.