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

The PRO side of above topic was debated in April 2013 by Erin Lowery, MD (see 2013 April Battling Links). Below is another submission on the PRO side of this topic.

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An extra lung transplant fellowship is not necessary to produce highly functioning lung transplant physicians. Pulmonary/critical care fellowship provides the foundation for an adequate knowledge base to care for the severely advanced lung disease patient prior to lung transplantation. Current training goals of pulmonary/critical care fellowship include competency in the diagnosis and management of obstructive and interstitial lung diseases. These are the two most common indications for transplantation. Initial fellowship training with subsequent patient experiences provides the tools necessary to determine risk for morbidity/mortality without transplantation. This is a key factor necessary to determine appropriate timing for listing for transplant and allow for the maximum survival and quality of life benefit following transplantation.

In addition, pulmonary fellowship training provides the backbone for management of the complex immunocompromised transplant recipient. Pulmonary fellows learn key infectious disease concepts in this population through consultative management of individuals who are solid organ recipients, bone marrow transplant patients, and those with acquired immunodeficiencies such as as the immunocompromised oncologic patient. These experiences allow the well trained fellow to generate appropriate broad differential diagnoses that include atypical and unusual infectious pathogens as well as non-infectious etiologies of lung diseases.

Furthermore, pulmonary and critical care fellowship provides key insight into the management of the critically ill patient including complex ventilator management, cardio-pulmonary physiology, and management of multi-system organ failure. Procedurally, the graduating fellow is accomplished in airway management, line placement, pulmonary artery catheter interpretation, bronchoscopy, and bedside ultrasonography. As ECMO continues to become more widely available, this too is a skill that the critical care fellow will have familiarity. These skills allow for adequate bridging of the awaiting transplant candidate. They are also necessary for the early post operative management of the recipient as well as those who develop early and late complications following lung transplantation.

Although it is true that further experience with this specialized subset of pulmonary patients through an additional year or two of training may provide valuable experiences to the future transplant pulmonologist, there are some real limitations to this approach as well. As we all know, lung transplantation occurs on its own timetable. This often means the donor assessment, management, procurement, implantation, and post-operative management occurs over many consecutive hours. These often span the night and extend well into the following day or days. These shared responsibilities of the transplant physicians and surgeons occur in addition to ongoing clinic, inpatient ward, and ICU call schedules. Current work hour restrictions for trainees limit the extent of exposure that one can master in a short year of additional training. Rather, one can argue that the gamut of transplant experiences that a new young faculty member, unencumbered by such work hour restrictions and with good mentorship, provides the best and most efficient pathway to a long and fulfilling career in lung transplantation.

Timothy Whelan, MD
Medical University of South Carolina

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

NEXT MONTH: We are looking for someone to refute the statements by Drs. Lowery and Whelan with a piece supporting the need for a lung transplant fellowship to prepare a pulmonologist for a career caring for lung transplant recipients. If interested, please contact Susie Newton or Daniel Dilling for details on how to submit your point of view.