Should some lung transplant programs stop?

Should some lung transplant programs stop?

There are about 65 lung transplant programs in the United States, but 85% of surgeries are performed by only about 20 programs. Either way, even the smallest programs — some that only do a handful of transplants a year — need adequate staff to stay open. As in many areas of the global collective workforce, the supply of doctors specializing in lung transplants is shrinking, while at the same time the total number of lung transplants is expected to increase due to the ravages of COVID-19 on lung health.

Should some of the smaller transplant programs close?

Common sense would dictate this, but, as with many sectors of our health economy, the question is more complicated and the answer less obvious than one might think. Here’s why.

Even though they are small, hospitals want their transplant programs to remain open for two reasons: First, the centers want the availability of all solid organ transplants (heart, kidney, liver and lung) in order to facilitate the ” One Stop Shop” for insurance companies that want to contract on all organ lines. Second, the existence of a transplant program of any type of organ brings collateral business to the hospital in that particular disease group, creating upstream and downstream revenue that is difficult to replace once that they disappeared.

The 2022 meeting of the International Society for Heart and Lung Transplantation (ISHLT) in Boston last spring was illuminating in many ways – not only because it was the first in-person meeting of cardiothoracic transplant professionals since 2019, but also because it was an opportunity for the transplant community to celebrate a milestone: more than 40,000 people are now transplanted each year — a number that continues to grow — and patients are living longer. Despite these positives, I left the meeting with a sense of concern as the insufficient number of lung transplant physicians and surgeons to staff existing transplant programs is getting worse. I could barely walk 50 feet through the convention center without someone stopping me and asking, “Do you know any lung transplant doctors looking for a new job?” We have a job offer. »

Physician shortages are not a new problem, nor confined to the field of transplantation, but it is a growing problem in the field of lung transplantation, due to the growth of the field in general and a labor that is not replenished to meet demand. The acute and chronic effects of COVID-19 pneumonia have increased, and this will have a domino effect on the volume of lung transplants performed. When it comes to the transplant workforce, lack of person power is a pre-pandemic issue that will only get worse as we move on from the acute phase of the pandemic.

So why the lack of qualified people to staff these programs?

When I asked this same question of the pulmonary medicine trainees when I was at Stanford – the group from whom we expected to get our candidates for the lung transplant fellowship – the answers were both painful and not completely unexpected. . Patients who regularly die, lack of control over working hours, and the responsibility of carrying a waiting list full of patients who could deteriorate at any moment are features of the job that are not exactly appealing to the current generation of physicians less swayed by the miracle of the transplant, the euphoria when everything went well, and the deep gratitude this group of patients regularly show to the transplant providers. These are all elements of the job that I loved – and missed when it was time for me to step away from the front lines. In many ways, interacting with the field now in a consulting role, I can see the interest of these young doctors looking for a different career path. Perhaps they are right to protect themselves from the rigors of the terrain.

But how does the shortage of transplant clinicians affect patients? In a word, unfavorably. Patients who are cared for by harassed and stretched thin clinicians suffer poorer outcomes. These clinicians are still on the proverbial hamster wheel, being urged by hospital administrators to do more transplants and by regulators and insurance companies to produce better results. When I evaluate a program with outcome issues in my consulting practice, problem number one is almost always simple: the lack of properly trained doctors, either younger ones to handle the growing number of beneficiaries, or, which is even more worrying are mid-career doctors. who have the vision, expertise and commitment to lead programs in an increasingly complex transplant environment. In fact, many of the most experienced doctors in some of the best programs in the country are looking for a way out, long before what would be considered a “normal” retirement.

What is the solution ?

First, we need to use technology to take the strain off transplant teams, especially around the physically exhausting organ harvesting process (flying in the middle of the night to retrieve organs from a distant hospital) , expensive and requires personnel that many transplant programs do not have.

Additionally, the surgeons who travel across the country in the middle of the night to procure organs are often the same ones who have cases scheduled for the next day, such as complex heart surgeries. Would you like your heart surgery to be performed by the surgeon who removed the organs the night before or by the one who slept at home? Easy answer.

Technologies to keep organs “alive” exist, keeping organs viable until a daytime transplant operation can be scheduled, but currently are not fully adopted by transplant centers, in largely due to a lack of technical familiarity with these new systems, a lack of understanding of the reimbursement issues of these technologies and, frankly, an unwillingness to embrace the future of transplantation.

Second, transplant programs need to implement a different model of care based less on using trainee physicians to do the work and more on non-physician team members who can follow treatment protocols to do the work. routine therapy adjustments, maintaining electronic medical records, and seeing transplant patients who are stable in the outpatient setting. Using this model not only helps provide a more streamlined life for interns and more experienced physicians, but also provides patients with continuity of care, a familiar face that will remain long after the interns leave for other opportunities. .

The responsibility for obtaining the necessary infrastructure to make the environment for transplant care more pleasant will fall to the program directors who will have to demonstrate convincingly to their hospital administrators that this path is the only way forward.

Third, hospitals must continue to foster an environment where physician well-being is a priority. Many are beginning to do so – an encouraging trend propelled by the pandemic, not only for the provider themselves but also for the good of the patient. Studies have unequivocally demonstrated that health care providers who have found a balance between their life outside the hospital and their life inside the hospital provide better care.

Finally, the most controversial solution. If there is an ever-expanding group of patients who need specialized and committed care, a classic supply and demand problem arises when supply (in this case, lung transplant physicians and surgeons) seems very unlikely to increase anytime soon. Therefore, we need to reduce the demand by reducing the number of lung transplant programs.

Having been in the transplant business for decades, I am fully aware that hospitals will not voluntarily shut down their transplant programs in order to serve a greater good. There are too many tempting financial and competitive incentives for a hospital to consider closing unilaterally. But some should, because not being able to adequately serve this group of very sick patients in a way they deserve violates every tenet of our profession.

We don’t need our current number of transplant programs, rather we need the number that best serves our patient population. And that means, less.

David Weill, MD, is the former director of the heart and lung transplant program at Stanford University. He is also the author of “Exhale: Hope, Healing, and a Life in Transplant”. He is also a board member of TransMedics.

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