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"A transplant fellowship is NOT necessary for a career in lung transplant pulmonology."

links imageThe system of apprenticeship was first developed in the Middle Ages, where a master craftsman employed young people as an inexpensive form a labor in exchange for food, lodging, and formal training in the craft. After completion of their contract, usually a term of seven years, they were free to acquire their own workshops. Our formal medical training system of modern times is not too dissimilar to this antiquated definition of apprenticeship. In addition to the 6 years following medical school that pulmonologists train in their craft, some have suggested that a transplant fellowship is necessary for a career in lung transplantation. I plan to convince you otherwise.

A transplant fellowship is not necessary to become a transplant pulmonologist, but what is necessary is a carefully planned and focused pulmonary fellowship at a busy transplant center with strong mentors in lung transplantation. Early in my pulmonary/critical care fellowship, a career in transplant pulmonology piqued my interest. Accordingly, during fellowship I deliberately allowed for plenty of exposure to lung transplantation, taking advantage of research opportunities and attending conferences focused on lung transplantation, which provided the foundation for a career in transplant pulmonology. This base training was much more valuable in my preparation as a transplant pulmonologist than an additional year of training in a transplant fellowship earning PGY7 salary, and moonlighting incessantly in order to make up the salary difference.

During my pulmonary/critical care fellowship I purposefully rotated on our lung transplant service often, in order to gain exposure to the medical management of these complex patients. Throughout my fellowship, performing bronchoscopies on lung transplant recipients was plentiful, and I encountered such issues as anastomotic dehiscence diagnosed via bronchoscopy, bronchostenosis, and PTLD in the trachea, to name a few examples. Taking extra effort to attend our weekly multidisciplinary lung transplant board meetings, I was educated on the issues grappling our transplant recipients and learned how my mentors would handle such issues. From these meetings I learned which candidates are appropriate for transplantation and when to consider retransplantation. Performing lung transplant research with a strong mentor, as I was fortunate during my fellowship, furthered my knowledge in lung transplantation. It also led to additional opportunities as a junior faculty member, undertaking an early career registry award, allowing me to work with statisticians at ISHLT on lung transplant registry data.

In addition to mentors and opportunities during my pulmonary fellowship, I took advantage of opportunities through the ISHLT. By attending the ISHLT Academy Core Competencies in Lung Transplantation in San Diego 2011, I was able to learn the basics and the most up to date knowledge from the experts in lung transplantation. Attending the ISHLT conference during my fellowship enhanced my knowledge of the latest research in lung transplantation, and introduced me to the lung transplant community.

As you can see, a separate transplant fellowship in lung transplantation is not necessary, particularly if steps are taken during pulmonary fellowship to enhance lung transplant knowledge. An additional year of training would only have been just that, an additional year of training. No one has mastered their trade by the completion of their 'apprenticeship'. It is the valuable early years in practice when the learning curve is highest. Don't we all continue to learn after the completion of our ACGME fellowship? It seems that fellowships have become continually more and more specialized, adding years and years to an already prolonged training process. At some point, the training wheels need to come off and the fellow needs to advance to the attending level. Adding additional years of servitude does not necessarily make the transition easier. Instead, focusing on continuing to learn and continuing to find opportunities and networks in the transplant community, will strength and smooth the transition from fellow to attending.

Erin Lowery, MD, MS
Assist Prof Medicine and Pediatrics
Loyola University Medical Center, Maywood, IL

NEXT MONTH: The CON side of this debate topic will be addressed by Timothy Whelan, MD, Associate Professor of Medicine at the Medical University of South Carolina in Charleston, SC.

Disclosure Statement: The author has no conflicts of interest to disclose.

Dr. Lowery is an Assistant professor of medicine and pediatrics at Loyola University Medical Center in Maywood, Illinois. After completing her medical school, residency, and pulmonary/critical care fellowship at Loyola, Erin joined the faculty in August 2011. She has completed a Masters degree in Clinical Research and Epidemiology. Her interests include lung transplantation and cystic fibrosis.