A German survey of the abdominal transplantation surgical work force

[Centralisation of Liver Transplantation: Implications for Training Transplant Surgeons]

The centralisation of liver transplantation in Germany is seen as a promising approach to improve care quality through higher case volumes and specialised structures. However, it poses significant challenges for surgical training. Reduced availability of training positions, limited diversity of clinical experience, and the risk of capacity bottlenecks could impact the education of young transplant surgeons in the long term. This article explores the opportunities and risks of centralisation, particularly regarding surgical education. While higher case volumes are associated with better outcomes, it is argued that complementary measures such as regional support structures, rotation programs, and, where applicable, the use of practical training models are essential to ensure comprehensive education. The implementation of regulations of minimum case volume is also discussed as a potential regulatory tool. Finally, the article highlights the need for future studies to systematically evaluate the impact of centralisation on surgical education and to provide an evidence-based foundation for decision making.

An analysis of fellowship training of kidney transplant surgeons in a Brazilian state

INTRODUCTION

The lack of specialized professionals potentially contributes to the inability to meet the demand for kidney transplantations. Moreover, there is no universal proposal for the training process of transplantation surgeons. We aimed to explore the characteristics of the training program and professional activities of kidney transplantation teams in the state of Minas Gerais, Brazil.

METHODS

We invited the surgeons of all 19 active kidney transplantation centers in Minas Gerais to participate in this cross-sectional study. Demographic and professional training data were compared using linear and logistic regression models.

RESULTS

The response rate among the centers was high (89%); half of the surgeons answered the survey (39/78). Most of the centers were public teaching institutions, under a production-based payment contract, with a mean of 6 ± 2.4 surgeons/team; 94.2% of the centers had urologists. The surgeons were 95% male (age of 46.3 ± 9.7 years) and 59% were urologists. Most were involved in organ procurement and transplantation; only one surgeon worked exclusively with transplantation. The mean period since training was 13 ± 9.4 years, with a mean of 10 ± 9.7 years as part of the transplantation team. Only 25.6% had specialized or formal training in transplantation, with only one completing a formal medical residency for kidney transplantation. The lack of training programs was the most frequently cited reason.

CONCLUSION

Kidney transplantation surgeons are not exclusive and most have not completed a formal fellowship program in transplantation because they are not available. These data indicate the need to improve training programs and facilitate the formation of new kidney transplantation teams.

The sex disparity in liver transplantation

PURPOSE OF THE REVIEW

This review describes the sex disparity in liver transplantation (LT) and explains its underlying causes.

RECENT FINDINGS

There is a small but persistent sex disparity in transplant rate and waitlist mortality that disappears once women are listed as Status 1. Allocation systems that could replace the Model for End Stage Liver Disease (MELD)-Na with scores less reliant on serum creatine and muscle mass have the potential to alleviate part of the sex disparity. Women perform worse on frailty assessments and are more likely to have nonalcoholic steatohepatitis (NASH). A diagnosis of NASH is compounding risk factor for frailty.

SUMMARY

Women remain disadvantaged in their access to LT despite multiple evolutions of the allocation system. An allocation system that relies less heavily on serum creatinine could partially alleviate the sex disparity. As NASH becomes more prevalent and frailty becomes more important in listing decisions, we may also need to carefully consider differences in the manifestations of frailty between the genders.

Gender and racial disparities in the transplant surgery workforce

PURPOSE OF REVIEW

This review explores trends in the United States (US) transplant surgery workforce with a focus on historical demographics, post-fellowship job market, and quality of life reported by transplant surgeons. Ongoing efforts to improve women and racial/ethnic minority representation in transplant surgery are highlighted. Future directions to create a transplant workforce that reflects the diversity of the US population are discussed.

RECENT FINDINGS

Representation of women and racial and ethnic minorities among transplant surgeons is minimal. Although recent data shows an improvement in the number of Black transplant surgeons from 2% to 5.5% and an increase in women to 12%, the White to Non-White transplant workforce ratio has increased 35% from 2000 to 2013. Transplant surgeons report an average of 4.3 call nights per week and less than five leisure days a month. Transplant ranks 1st among surgical sub-specialties in the prevalence of three well-studied facets of burnout. Concerns about lifestyle may contribute to the decreasing demand for advanced training in abdominal transplantation by US graduates.

SUMMARY

Minimal improvements have been made in transplant surgery workforce diversity. Sustained and intentional recruitment and promotion efforts are needed to improve the representation of women and minority physicians and advanced practice providers in the field.

Organ utilization - the next hurdle in transplantation?

Nonutilization of organs from consented deceased donors remains a significant factor in limiting patient access to transplantation. Critical to reducing waste is a clear understanding of why organs are not used: accurate metrics are essential to identify the extent and causes of waste but use of these measures as targets or comparators between units/jurisdictions must be done with caution as focus on any one measure may result in unintended adverse consequences. Comparison between centres or countries may be misleading because of variation in definitions, patient or graft characteristics. Two of the most challenging areas to improve appropriate deceased donor organ utilization are appetite for risk and lack of validated tools to help identify an organ that will function appropriately. Currently, the implanting surgeon is widely considered to be accountable for the use of a donated organ so guidelines must be clear to allow and support sensible decisions and recognition that graft failure or inadvertent disease transmission are not necessarily attributable to poor decision-making. Accepting an organ involves balancing risk and benefit for the potential recipient. Novel technologies such as machine perfusion may allow for more robust guidance as to the functioning of the organ.

Gender Disparities in Authorships and Citations in Transplantation Research

Background.

Over the past decades, there has been a rapid change in the gender ratio of medical doctors, whereas gender differences in academia remain apparent. In transplantation research, a field already understaffed with female doctors and researchers, there is little published data on the development in proportion, citations, and funding of female researchers over the past years.

Methods.

To evaluate the academic impact of female doctors in transplantation research, we conducted a bibliometric analysis (01 January 1999 to 31 December 2018) of high-impact scientific publications, subsequent citations, and funding in this field. Web of Science data was used in combination with software R-Package “Gender,” to predict gender by first names.

Results.

For this study, 15 498 (36.2% female; 63.8% male) first and 13 345 (30.2% female; 69.8% male) last author gender matches were identified. An increase in the percentage of female first and last authors is seen in the period 1999–2018, with clear differences between countries (55.1% female authors in The Netherlands versus 13.1% in Japan, for example). When stratifying publications based on the number of citations, a decline was seen in the percentage of female authors, from 34.6%–30.7% in the first group (≤10 citations) to 20.8%–23.2% in the fifth group (>200 citations), for first (P < 0.001) and last (P = 0.014) authors, respectively. From all first author name-gender matches, 6574 (41.6% female; 58.4% male, P < 0.001) publications reported external funding, with 823 (35.5% female; 64.5% male, P = 0.701) reported funding by pharmaceutical companies and 1266 (36.6% female; 63.4% male, P < 0.001) reporting funding by the National Institutes of Health.

Conclusions.

This is the first analysis of gender bias in scientific publications, subsequent citations, and funding in transplantation research. We show ongoing differences between male and female authors in citation rates and rewarded funding in this field. This requires an active approach to increase female representation in research reporting and funding rewarding.

A survey of Heads of Surgery and Residents on accessibility and employment in liver transplant teams in Spain

INTRODUCTION

The access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders' view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice.

METHODS

Two different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents.

RESULTS

There are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed. Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future.

CONCLUSIONS

The generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results.

Sent Liver Grafts Do Not Have a Detrimental Impact on Post-transplant Outcome

INTRODUCTION

"Sent livers" (SL) (interregional allocated organs) are considered extended donor criteria grafts. These grafts influence post-transplant outcome. In our donor allocation program, the number of allocated SLs is increasing. The aim of our study is to provide data supporting the possibility to enlarge the use of SLs through adequate donor-to-recipient matching.

METHODS

A retrospective analysis was carried out from our prospective-collected database during 2014.

RESULTS

Fifty-seven liver transplantations (LTs) were included: 22 SLs and 35 grafts procured by us (nSLs). Only donor risk index among donor characteristics showed a trend toward significant values (SL 1.901 vs nSL 1.726, P = .07). Among LT variables, the number of patients who received interleukin-2 inhibitor induction (SL 7 vs nSL 20, P < .05) and the presence of hepatocellular carcinoma (SL 50% vs nSL 34%, P < .05) reached statistical significance. One case of primary nonfunction occurred in the nSL group. No major retrieval injuries were observed. Retransplantation was performed in 6 cases (2 SLs and 4 nSLs). One patient in the SL group died after retransplantation. Graft survival rates at 1, 3, 6, and 12 months were 100%, 100%, 90%, 86% and 91%, 86%, 86%, 86% (P = .79) in SL and nSL groups, respectively.

DISCUSSION

SL performance did not differ from that of nSL. SLs were usually allocated to noncritical candidates, and nSLs were transplanted more frequently in decompensated recipients. Despite this peculiar donor-recipient match, grafts survival was similar in the 2 groups of patients.

Career intentions of female surgeons in German liver transplant centers considering family and lifestyle priorities

PURPOSE

Women represent up to 60 % of students entering the medical profession in many countries in the world. However, the proportion of women to men is not accordingly balanced among surgical residents and especially in leadership positions in surgery. Therefore, we investigated the career goals as well as family and lifestyle priorities of female surgeons in German liver transplant centers.

METHODS

A standardized questionnaire was developed using the web-based survey tool SurveyMonkey®. Questionnaires were distributed electronically to 180 female surgeons in 24 German liver transplant centers. A total of 81 completed questionnaires were analyzed.

RESULTS

Female surgeons in German liver transplant centers are eager to assume leadership positions and do not wish to follow traditional role models. After finishing training, most female surgeons plan to continue working at a university hospital. About 80 % of the respondents intend to continue working full time and wish to combine career and family.

CONCLUSIONS

This is the first survey on career intentions of female surgeons in Germany. In the face of gender changes in the medical profession, we were able to demonstrate that female surgeons are willing to fill leadership positions. Individual and institutional creative modifications are necessary if the advancement of women in surgery is to be promoted.