Do you want to know what’s keeping me up at night (besides of course the 2 AM donor call)? It’s actually who is going to take that donor call in 5, 10 or 20 years.
Having been involved for more than 20 years in the education of fellows interested in lung transplantation, I have witnessed a trend over the last several years. And not a good one. While at Stanford, I noticed a sharp decrease in the number of applicants for our lung transplant fellowship spot, despite that fact that we had the oldest and best established lung transplant training program anywhere, begun by my predecessor Jim Theodore. As the years went on and the number of people applying for the spot dwindled, I began to check around with my colleagues around the country who had a history of training fellows. Same problem everywhere. Although relieved to know it wasn’t just a Stanford problem, some years we struggled to find even one person who wanted to train with us – this past July, for the first time in the twenty plus years of the Stanford fellowship program, there is no dedicated person training in lung transplantation. In the carefully chosen words of our new President: Sad.
So what’s going on out there? Why aren’t more people interested in focused training in lung transplantation, a field that holds endless fascination and satisfaction to many of us? I don’t think it has much to do with the fine lung transplant people at Stanford or with someone like Marty Zamora who has historically trained a number of people who have gone on to have long careers in the field (although he rarely admits that I was his first trainee back in the early 1990s). No, instead, there are a number of other factors drawing young people away from the field. And I get this information not only from talking with doctors I tried to recruit to our fellowship program but also through my current work helping several transplant programs confront various challenges.
What are the challenges in trying to get young physicians interested in our field?
First, lifestyle. Our patients are the sickest of the sick, can turn bad on a dime, and need us all the time. It’s tough work and today’s trainees have other options, all of which have good pay, controllable hours, and a more straight-forward patient group to take care of. Our patients are complex, to say the least, and caring for them requires some degree of discomfort with uncertainty. At the risk of sounding 108 years old, it seems to me that younger physicians today are less comfortable with medical uncertainty than we were, less willing to trust their gut. If you want to be sure about everything all the time, lung transplant may not be for you.
Second, the training period is hard. We have 12 months to teach fellows how to do lung transplant. It’s not enough time. So in our non-ACGME approved program, we worked them hard. And told them before they signed up that we were going to. Most loved it but some considering the idea of training with us probably thought to themselves, “No thanks. Sleep medicine sounds good.”
Third, and worse than not wanting to do the rigorous year of training, many prospective trainees tell me, “I don’t want to do the fellowship, it looks like a beating, but to be honest, I don’t want to do what you do either.” And I think that’s an indication that there is a real problem. Throughout the history of medicine, training younger physicians has been characterized by a “grand bargain:” the acceptance of some personal sacrifice during the training period with the expectation of a better life once the training was complete. That was the deal. But the deal falls apart when the those considering training with you don’t want the training position AND they don’t want your job either.
Okay, there are less people formally training to be lung transplant doctors: so what? In fact, it’s a big deal. The number 1 problem with most programs that are struggling is simple: lack of properly trained lung transplant physicians, either young ones to handle the growing number of recipients demonstrating longer survivals or mid-career transplant doctors who have the vision, expertise, and commitment to lead programs in an ever more complex transplant environment. While this may sound okay for the lung transplant doctor reading this (“Great – job security!”), it’s not good for the field. Lung transplant is getting harder, not easier. There are more programs doing more transplants. Some are doing a huge number of transplants, numbers that I never thought a single program could do. And what is the common factor in all of these programs, both big and small? They nearly universally don’t have enough physicians. Bad for patients who are cared for by harried providers and bad for the harried provider who is the proverbial hamster on a treadmill, all the while being asked to do more transplants and provide better outcomes.
Okay what’s the solution? I think the only solution is for transplant programs to implement a different model, a model based less on using physician trainees for getting most (or all) of the work done and more on utilizing mid-level practitioners who can implement and execute protocols and take on significant roles in the overall care of the patient. Using this model not only achieves a more rational life for the trainee but also provides patients with continuity of care, a familiar face that will be around long after the trainees have left for other pastures. The responsibility of getting the infrastructure needed to make the training environment more palatable will fall on the program directors who will need to make a convincing case to their hospital administrators that this route is the only way forward.
But won’t we still need trained transplant doctors to manage the mid-level providers and advance the field? Yes, of course. But to attract young doctors to the field, we will need to tell them, and they will need to see, that the entire burden of the mundane tasks involved in this complex clinical care won’t fall on them. It will be a shared responsibility among everyone on the team. That may not be how you trained – it sure isn’t how I trained. But it is the way the next generation of lung transplant physicians will need to be trained.