There are around 65 lung transplant programs in the United States, but 85 percent of surgeries are performed in just about 20 programs. Regardless, even the smaller programs — some that only perform a handful of transplants a year — need enough staff to remain open. As in so many areas of the collective workforce worldwide, the supply of lung transplant doctors is shrinking, while at the same time, the total number of lung transplants is expected to rise due to the devastating impact of COVID-19 on lung health.
Should some of the smaller transplant programs be closed?
Common sense would dictate it, but as in many areas of our healthcare economy, the problem is more complicated and the answer is less obvious than you might think. Here’s why.
Even though they are small, hospitals want their transplant programs to remain open for two reasons: First, centers want the availability of all organ transplants (heart, kidneys, liver, and lung) to buy insurance companies that want to contract all organ lines “from a single source.” Second, the existence of a transplant program of any type of organ brings side business to the hospital in that particular disease group, resulting in turnover up and down that is difficult to replace once it is gone.
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The International Society for Heart and Lung Transplantation (ISHLT) 2022 meeting in Boston last spring was instructive 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 an important milestone: more than 40,000 people are transplanted annually — a number that continues to rise — and patients are alive longer. Despite these positive results, I left the meeting with concern because the insufficient number of lung transplant doctors and surgeons staffing the existing transplant programs is getting worse. I could barely walk 50 feet in the convention center without someone stopping me and asking, “Do you know lung transplant doctors who are looking for a new job? We have an open position.”
lack of doctors is not a new problem and is not limited to the transplant sector, but it is a problem that is worsening with lung transplants as the sector is generally growing and the workforce is not being resupplied to keep up with demand. The acute and chronic effects of COVID-19 pneumonia have increased, which will have a domino effect on the volume of lung transplants performed. As far as transplant workers are concerned, the lack of personnel power is a pre-pandemic issue that will only worsen as we leave the acute phase of the pandemic.
So why the lack of qualified personnel for these programs?
When I asked trainees in lung medicine at Stanford, the group we’d expect our lung transplant fellowships from, the answers were both harrowing and not entirely unexpected. Regular patient deaths, lack of control over working hours, and the responsibility to maintain a waiting list of patients who could get worse at any time are features of this work that are not exactly attractive to the current generation of doctors, who are less affected by the miracle of transplantation, by the euphoria when everything went well, and the deep gratitude that this group of patients regularly shows to transplant providers. These are all elements of the job I loved — and missed when it was time for me to part ways with the front lines. In many ways, in interacting with the area that is now working as a counselor, I can see the point of these younger doctors who are looking for a different career path. Maybe they’re right to protect themselves from the rigors of the field.
But how is the lack of transplant clinicians affecting patients? In a word, disadvantageous. Patients who are cared for by distressed, stretched, thin doctors suffer from worse outcomes. These clinicians are always on the proverbial hamster wheel, being asked by hospital administrators to do more transplants, and by regulators and insurance companies to get better results. When I’m evaluating a program with outcome issues in my counseling practice, the main problem is almost always simple: there is a lack of well-trained doctors, either younger ones, to deal with the growing number of recipients, or, more worryingly, mid-career doctors who have the vision, expertise, and commitment to lead programs in an increasingly complex transplant environment. In fact, many of the more experienced doctors of some of the best programs in the country are looking for a way out, far earlier than what would be considered a “normal” retirement.
What is the solution?
First, we need to use technology to relieve the burden on transplant teams, particularly in connection with the organ procurement process, which is physically demanding (flying out in the middle of the night to fetch organs from a remote hospital), costly, and requires staff that many transplant programs don’t have.
In addition, the surgeons who fly across the country in the middle of the night to obtain organs are often the same ones who have planned cases the next day, such as complex heart operations. Would you like your heart surgery to be performed by the surgeon who removed organs the previous night, or by a surgeon who fell deeply asleep at home? Easy answer.
While there are technologies that can be used to keep organs “alive” until a day transplant can be planned, they are currently not fully adopted by transplant centers, largely due to a lack of technical knowledge with these new systems, a lack of understanding of the reimbursement issues for these technologies and, frankly, an unwillingness to face the future of transplantation.
Second, transplant programs must implement a different model of care that is based less on using trainees to get the job done and more on team members without doctors who can follow treatment protocols to make routine treatment adjustments, take care of electronic medical records, and care for transplant patients who are stable in the outpatient clinic. Applying this model not only enables a more streamlined life for trainees and more experienced doctors, but also provides patients with continuous care, a familiar face that will last long after trainees have gone to other opportunities.
The responsibility for providing the infrastructure needed to make the transplant care environment more palatable lies with program directors, who must convincingly explain to their hospital administrators that this is the only path forward.
Third, hospitals must continue to promote an environment where doctors’ wellbeing is a top priority. Many are starting with it — an encouraging trend that has been driven by the pandemic not only for the provider herself, but also for the patient herself. Studies have clearly shown that healthcare providers who have achieved a balance between their lives outside the hospital and their lives within the hospital provide better care.
At last, the most controversial solution. When there is a constantly growing patient group that requires dedicated, specialized care, a classic supply and demand problem arises when it is highly unlikely that supply (in this case lung transplant doctors and surgeons) will increase in the foreseeable future. That’s why we need to reduce demand by reducing the number of lung transplant programs.
Having worked in the transplant sector for decades, I am fully aware that hospitals are not voluntarily shutting down their transplant programs to serve a greater good. There are too many tempting financial and competition incentives for a hospital to consider closing it unilaterally. But some should do that, as it is against every principle of our profession to be unable to provide adequate care to this very ill patient population in a way they deserve.
We don’t need our current number of transplant programs, just the number that best serves our patient population. And that means less.
David Weill, M.D., 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 Transplantation.” He is also a board member of TransMedics.