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A Career in Lung Transplantation - A Fellow's Perspective

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Nikita Desai, MD
Emory University
Atlanta, GA, USA

As I entered my fellowship, eager to immerse myself in the knowledge of pulmonary physiology, critical care, and advanced lung disease, I was struck by the unexpected and often frustrating role of managing my patients' expectations. Rarely did a patient walk into my Monday afternoon clinic with a complaint I could definitively cure. Most of the time I was counseling patients on their new diagnosis of a chronic, irreversible disease with difficult to manage symptoms. I found myself wishing I could do more, and that my paltry offerings inhalers, influenza vaccines, and pulmonary rehabilitation felt surprisingly inadequate. It wasn't until my rotation in lung transplantation that I was able to offer hope, however slim, to the patient with end stage lung disease. Suddenly I saw that patients who were substantially limited could finally be able to do things we take for granted: grocery shopping, attending a baseball game, traveling to visit family.

As a trainee, lung transplantation has allowed me to care for a patient using the same complex medical decision making that drew me to the intensive care unit in the first place. Managing chronic medical illness in conjunction with the evolving donor-recipient biologic model is both intellectually stimulating and clinically rewarding. Furthermore, to see a patient and their family through lung transplantation is to be given the opportunity to see the best in people. From intensive pre-transplant preparation, to rehabilitation, relocation, education, long hospital days, and countless follow up appointments in the post-transplant phase, patients and their families have shown unrelenting perseverance, sacrifice, dedication, and true grit.

As rewarding as it is to care for patients seeking lung transplantation, it is equally exciting to pioneer scientific innovation. In the past two decades, we've made significant strides in the realm of immunology and biopharmaceutics. Targeted genetic therapy has improved lung function in patients with Cystic Fibrosis, a disease which affects 30,000 people in the United States. The CF experience has shown that specifically addressing the intracellular trafficking of a misfolded protein can lead to a dramatic change in lung function. This raises optimism for lung transplantation, particularly if we can figure out the key intracellular signals that lead to luminal obliteration of the terminal airway. While the pathogenesis of Obliterative Bronchiolitis remains an enigma, this is an engineering problem to be solved, rather than an insurmountable hurdle.

By comparison, Chronic Obstructive Pulmonary Disease affects over 15 million people in the United States and the scientific community has made limited strides in improving mortality and length of life. One glance at a CT Scan of a patient with bullous emphysema is enough to convince even a lay person that pharmaceutical options are limited. Over the past three decades we've made gains in our ability to transplant older, sicker patients, and broaden our donor acceptability criteria; however, we continue to be limited by donor availability. Xenotransplantation could be one potential solution to this problem. It is this ability to address the needs of millions that drives us forward.

A trainee considering a career in lung transplantation is at the forefront of a field where there are more questions than answers, room for pharmaceutical and technological development, and a patient population eager for treatment options. Advancements in clinical, genetic, and environmental factors give promise to one day transitioning from center regulated transplant protocols to tailored patient specific therapy. It is my generation's duty to apply advancements in lung transplantation to other aspects of pulmonary disease. There has never been a more exciting time to enter the field of lung transplantation. ■

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

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