There are around 65 lung transplant programs in the United States, but 85 percent of the surgeries are performed by only about 20 programs. Regardless, even the smaller programs — some that do just a handful of transplants per year — require adequate staffing in order to stay open. As in so many areas of the world’s collective workforce, the supply of lung transplant doctors is dwindling, while at the same time the total number of lung transplants is expected to rise due to the ravages of COVID-19 on lung health.
Should some of the smaller transplant programs close?
Common sense would dictate so, but, as in many corners of our health care economy, the issue is more complicated, and the answer less obvious, than one would think. Here’s why.
Even if small, the hospitals want their transplant programs to stay open for two reasons: First, centers want availability of all solid organ transplants (heart, kidney, liver and lung) in order to facilitate “one stop shopping” for insurance companies who want to contract across all organ lines. Second, the existence of a transplant program of any organ type brings collateral business to the hospital in that particular disease group, creating up-and down-stream revenue that is hard to replace once it’s gone.
The 2022 International Society for Heart and Lung Transplantation (ISHLT) meeting in Boston last spring was enlightening in many ways — not just 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 now being transplanted annually — a number that continues to rise — and patients are living longer. Despite these positives, I left the meeting feeling concerned, because the inadequate number of lung transplant physicians and surgeons to staff the existing transplant programs is getting worse. I could barely walk 50 feet in the convention center without someone stopping me to ask, “Do you know of any lung transplant doctors looking for a new position? We have a job opening.”
Physician shortages are not a new problem, nor confined to the transplant arena, but it is an issue that’s getting worse in lung transplantation, due to growth of the field generally and a workforce that is not being resupplied in order to keep up with demand. The acute and chronic effects of COVID-19 pneumonia have increased, and that will have a domino effect on the volume of lung transplants performed. As it pertains to the transplant workforce, lack of person-power is a pre-pandemic problem that will only worsen as we leave the acute phase of the pandemic.
So, why the lack of qualified people to staff these programs?
When I posed this very question to pulmonary medicine trainees when I was at Stanford — the group from whom we would expect to get our lung transplant fellowship candidates — the responses were both distressing and not completely unexpected. Patients dying regularly, lack of control of work hours, and the responsibility of carrying a waiting list filled with patients who could deteriorate at any time are characteristics of the job that are not exactly attractive to the current generation of physicians who are less swayed by the miracle of transplant, the euphoria when things went well, and the profound gratitude that this patient group regularly displays to 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 frontlines. In many ways, interacting with the field now in a consulting role, I can see the point of these younger physicians looking for a different career path. Perhaps they are right to protect themselves from the rigors of the field.
But how does the lack of transplant clinicians affect patients? In a word, adversely. Patients who are cared for by harried, stretched thin clinicians suffer poorer outcomes. These clinicians are always on the proverbial hamster wheel, being urged by hospital administrators to do more transplants and by regulatory bodies and insurance companies to produce better outcomes. When I evaluate a program with outcomes issues in my consulting practice, the number one problem is nearly always a simple one: lack of properly trained physicians, either younger ones to handle the growing number of recipients or, even more concerning, mid-career doctors who have the vision, expertise and commitment to lead programs in an ever more complex transplant environment. In fact, many of the more experienced doctors at some of the best programs in the country are looking for a way out, far earlier than what would be considered “normal” retirement.
What’s the solution?
First, we need to use technology to unburden the transplant teams, particularly around the organ procurement process which is physically exhausting (flying out in the middle of the night to retrieve organs from a distant hospital), costly and requires staffing that many transplant programs do not have.
Plus, the surgeons who are flying around the country in the middle of the night to procure organs are often the same ones that have scheduled cases the next day, like complex cardiac surgeries. Would you like your heart surgery done by the surgeon that has retrieved organs the previous night or one that has been at home fast asleep? Easy answer.
Technologies to keep organs “alive” do exist, keeping organs viable until a daytime transplant operation can be scheduled but, currently, are not being fully adopted by transplant centers, largely due to lack of technical familiarity with these new systems, lack of understanding of reimbursement issues for these technologies, and, frankly, lack of willingness to embrace the transplant future.
Second, the transplant programs need to implement a different care model based less on using physician trainees for getting the work done and more on non-physicians team members who can follow treatment protocols for making routine therapy adjustments, tend to the electronic medical record and see transplant patients who are stable in the outpatient clinic. Using this model not only achieves a more rational life for trainees and more experienced physicians but also provides patients with continuity of care, a familiar face that will be around long after the trainees have left for other opportunities.
The responsibility of getting the infrastructure needed to make the transplant care environment more palatable will fall on the program directors who will need to make a convincing case to their hospital administrators that this route is the only way forward.
Third, hospitals need to continue to foster an environment where physician wellness is a priority. Many are starting to do so — an encouraging trend propelled forward by the pandemic, not only for the provider herself but also for the patient’s sake. Studies have shown unequivocally that health care providers that have achieved balance between their lives outside of the hospital, and their life within it, provide better care.
Finally, the most controversial solution. If there is an ever-expanding patient group that needs committed, specialized care, a classic supply and demand issue arises when the supply (in this case, lung transplant physicians and surgeons) seems very unlikely to increase any time soon. Therefore, we must cut the demand by reducing the number of lung transplant programs.
Having been in the transplant arena for decades, I am fully aware that hospitals won’t voluntarily close their transplant programs in order to serve some greater good. There are too many tempting financial and competitive incentives for a hospital to consider shutting down unilaterally. But some should, since not being able to adequately serve this very sick patient group in a manner that they deserve violates every tenet of our profession.
We don’t need our current number of transplant programs —we instead need only the number that best serves our patient population. And that means, fewer.
David Weill, M.D., is the former director of the heart and lung transplant program at Stanford University. He’s also the author of “Exhale: Hope, Healing, and a Life in Transplant.” He is also a board member of TransMedics.