transplant experience in residency

[swoopyswoop]

I'm trying to compare programs and decide how important certain things are to have in a residency. Most programs are vastly the same with a few small exceptions:

- transplant experience: everywhere I've been does kidneys; not everywhere does livers. Very very few do lungs (obviously), mixture of who does hearts. How important is this? I enjoyed my transplant experience as a student, and while I know the resident isn't going to be first assist in a liver when a fellow is scrubbed in, I would think experience managing pre- and post-op liver patients is good for a resident to have. (I mainly ask because my #1 place by "feelings" doesn't do livers)

- burn experience: again, obviously confined to burn centers. also seems like a good experience to have as a resident, but youll probably get enough fluid resuscitation / critical care during trauma/ SICU months.

- VA rotations. resident friends have told me this is a must, for the autonomy, late presentations, sick patients, etc. A few of the places I loved don't go to a VA.

I know no one can make my rank list for me, but I was just hoping for some input on the pros/ cons of having/ not having the above and if they should be important in my rank list of if I'm overblowing their significance.

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[WinslowPringle]

I'm only an intern, so I haven't rotated through all of the above rotations. I do think they are important options to think through. But to jump off "most programs are vastly the same" - a PD on the trail said "Nearly all accredited residencies + your own hard work will prepare you well enough to become a safely practicing board-certified surgeon. They have mainly the same things. The big difference is the people and the culture." I'd tend to agree - so if your gut is telling you that there is a program that would offer excellent training that would otherwise be the best place to prepare you for your career goals, strongly consider ranking them first even if they don't do livers.

On burn - if you're looking at a place that doesn't do burn and want to get your critical care hours on trauma/SICU, then make sure the place has solid trauma/SICU rotations so you can get that experience.

On VA - It's not a 'must' as long as the home program has the level of autonomy and sick patients to make up for it. (Making broad generalizations, I found the 'strictly University' residents tended to like the VA because that is where they got their autonomy, whereas some of the smaller programs felt it was annoying because they had a decent level of independence in their home program and didn't want to be shipped off to a poorer work environment to get it.)

 

[swoopyswoop]

Thank you!

I just wonder how someone can make an educated decision about what field to enter if they don't have experience in it as a resident - what if deep down inside I'm a liver transplant expert waiting to be discovered?!

I'm only looking at academic programs so they all suffer from autonomy deficiency which is maybe why I've been told a VA is so important for training.

 

[surg]

A county hospital or good community experience can sometimes be a good substitute for the VA. I loved my VA experience, but others really disliked it, so I think you should pay attention to your gut in terms of whether you think you would fit there. The most important thing is that the chief residents when they are done feel like they can do an operation skin to skin whether the attending showed up or not by the end of their residency. That is the ultimate goal. How a program chooses to accomplish that is not as important, so long as they do.

In terms of burn, if you don't have a good burn experience, it would be beneficial to rotate on plastics. Being able to do a good skin graft, and to do scar releases and rotation and transposition flaps will help a lot with figuring out how to close large wound defects without having to always consult plastic surgery for run of the mill things. I couldn't stand how hot the burn operating rooms were, but the operations were great as a junior resident as they often provided a fair bit of autonomy, and a lot of sewing practice beyond the critical care aspects of burn.

Transplant: lung/heart transplants are probably only important for a general surgery resident in terms of the critical care. You aren't probably ever going to scrub one in training or after unless you choose to do a CT fellowship or integrated track. I wouldn't worry about it at all. Liver transplant has 2 nice benefits for the general surgery resident. Going on harvests for Livers can be very educational anatomy-wise, whereas it is rarer I think to go on a kidney only harvest as they as usually done by a local surgeon (or the ones coming for the liver) and then shipped. The anatomy of doing a complete hepatectomy will make you a better liver surgeon someday. Unfortunately few programs I think are allowing their residents to be the primary surgeon on the liver transplants, too many fellowships, and the worries about outcome comparisons seem to be pushing this into decline. Having said that, scrubbing into these operations can be very educational. In addition, many liver transplant surgeons also do liver resections for other things and the existence of a liver transplant service gives options to the oncologic surgeons that they might not otherwise have for HCC so there is that. Finally, the educational benefit (and pain) of doing other operations on liver failure patients who are waiting for transplant, such as the rupture umbilical hernia, and learning to manage those patients is worthwhile, although I would suggest that if you desire to practice in the community, you will end up refer many of those to the university anyway.

Hope that helps. In the end though, all that aside, if you go to a program that you don't "fit" with just to get those experiences, you will be unduly miserable everyday and that probably doesn't make up for the marginally higher educational value that the "perfect" program might be able to provide. My standard advice is to "go to the best program that you can thrive at", with the emphasis on the last part of the phrase, and less on the "best" part.

Good luck!

 

[swoopyswoop]

Thanks for all your input. Definitely sounds like a liver transplant program or at least a good hepatobiliary service will be important components for a residency program. Some of my favorite cases during my surgery clerkship were transplant procurements and the residents who went got a lot of hands on experience during these as well. I know of one resident who was very interested in trauma at a relatively non-trauma-heavy program who did a month at one of the classic trauma centers during his research years. I wonder if this might be an option at a program w/o a liver transplant service?

I did a medicine month at the VA and learned far more from the patients there than from the patients at my university program but the interns were not very happy that month.

Another program I really liked is a big academic program, very strong with research, but the residents operate at their home university program and a fancy rich private hospital in the suburbs, so I worry about their operative experience compared to a program where you are at a VA or a public/county hospital for part of your rotations.

 

[swoopyswoop]

All good things to know. Thanks for your input. I'm wondering if the relative program strengths of my # 2-5 on my rank list should be more important than how much I viscerally loved program #1 on my list (which is really only lacking in liver txplts, has burn & VA)...

#1: no liver txplt, + everything else (VA, burn)
#2: + livers, + VA, no burn
#3: + livers (on the lower side), + burn, no VA or community hospital experience except trauma
#4: + livers (lots of living donor + deceased donor), + VA, no burn
#5: +VA, no burn, no livers
#6: + VA, + livers, + burn
#7: + everything but not a city I particularly want to spend 7 years in

... and on and on.

If anyone wants to hear me out on the specific programs I'm looking at and their relative strengths / weaknesses let me know!

 

[swoopyswoop]

So what do I make my decision based on?!

 

[swoopyswoop]

If anyone has any specific thoughts on these programs / their relative strengths and weaknesses that would also be super helpful:

(In no particular order):
Wash U
U Chicago
UC Davis
Baylor
Northwestern
UW Madison

 

[swoopyswoop]

That's very interestingly almost the exact opposite of my current rank list!

 

[Winged Scapula]

That's very interestingly almost the exact opposite of my current rank list!

While you could quibble about some of the middle programs, SS has the order correctly in terms of training rep.

 

[swoopyswoop]

Can you elaborate on placing UC Davis at the bottom of the list? They seem to get a good exposure to all fields (minus liver txplt), and have attracted a lot of big names recently (Frieschlag from hopkins, Farmer from UCSF). I agree they're not on the reputation level of Wash U/ NW / Chicago, but it seems like your training would be fairly equivalent at all those institutions, and they all match reasonably well.

 

[thedrjojo]

Ss has been on point so I won't change or add much, but transplant also depends on fellow vs no fellow. There's no fellow here and we do close to 50 livers a year, only Vanderbilt has higher volume with residents and no fellow that I know of. So the pgy4 runs that service, although this year they changed to 2 attendings doing the hepatectomy, I still helped sew in the liver when I got back from the procurement.

I'm also skewed on the "University Hospital" having the worst autonomy, cause that's the exact opposite in my experience, but that's cause my uh is the county hospital and the biggest provider of charity care in the state. But a VA was a big part of my decision and I couldn't imagine training without it. I'm also glad to not have burn, but I get 5-6 months of sicu, so I'm fine with nearly any sick pt.

 

[thedrjojo]

I heard vandy is getting a fellowship

Not for this year it seems

 

[TypeADissection]

Gonna throw my 2 cents in. I'm a PGY-3 at a large, tertiary "privademic" institute that actually does no transplant. We used to in the past and then the dudes that did it either retired or got recruited elsewhere. So we go to an even larger, academic tertiary place for one month as a third year to do transplant. I was assigned to the kidney-panc service and it was an eye-opening experience. You have some general surgery days doing lap PD caths, fistulas, incisional hernias, etc. Then you have days where nothing happens and then everything is a go and a disparate number happens to take place between 2200-0200. There was no chance they were ever gonna let me (or any general surgery resident) sew any part of a liver in, but doing kidneys is actually a lot of fun and that's where most of us get our experience. That and going on procurements with a really good fellow/attending who wants to teach and is willing to teach you technique and dissect stuff out.

FYI, there's in inordinate amount of waiting that takes place in transplant. You get somewhere around 1600 and think it's gonna be in and out, then you sit around for hours...and hours... Incision takes place around 2000 and it really sucks when you turn down the organ because then you sat around and burned all this time you could've been home doing laundry, sleeping, studying, working out, etc.

For me personally, I'm glad transplant isn't a regular part of my program just due to the unpredictability of it all. But I respect the hell out of those guys. They are unflappable. They have great economy of motion in how they operate, they reconstruct all sorts of crazy things and the surgeries are really cool. Good luck. Cheers.

 

[thedrjojo]

Gonna throw my 2 cents in. I'm a PGY-3 at a large, tertiary "privademic" institute that actually does no transplant. We used to in the past and then the dudes that did it either retired or got recruited elsewhere. So we go to an even larger, academic tertiary place for one month as a third year to do transplant. I was assigned to the kidney-panc service and it was an eye-opening experience. You have some general surgery days doing lap PD caths, fistulas, incisional hernias, etc. Then you have days where nothing happens and then everything is a go and a disparate number happens to take place between 2200-0200. There was no chance they were ever gonna let me (or any general surgery resident) sew any part of a liver in, but doing kidneys is actually a lot of fun and that's where most of us get our experience. That and going on procurements with a really good fellow/attending who wants to teach and is willing to teach you technique and dissect stuff out.

FYI, there's in inordinate amount of waiting that takes place in transplant. You get somewhere around 1600 and think it's gonna be in and out, then you sit around for hours...and hours... Incision takes place around 2000 and it really sucks when you turn down the organ because then you sat around and burned all this time you could've been home doing laundry, sleeping, studying, working out, etc.

For me personally, I'm glad transplant isn't a regular part of my program just due to the unpredictability of it all. But I respect the hell out of those guys. They are unflappable. They have great economy of motion in how they operate, they reconstruct all sorts of crazy things and the surgeries are really cool. Good luck. Cheers.

Depends on the program. Our residents regularly sew the portal vein and bile duct. My kidney experience I so far have only sewed the ureter, but my attending claims I get to be on the surgeon side from the beginning next case. We shall see on my living donor tomorrow...

 

[thedrjojo]

I've only ever done one kidney where I didn't sew all three anastomoses, and that was on a small child. Still sewed 2/3 but the attending did the artery.

My program did 16 kidneys last year (yet I managed to have 4 in one week). They are super protective. The old kidney guy would have you sew everything... Im looking forward to fellowship where I can let the resident sew everything

 

[thedrjojo]

Fair nuff

Did my side of the vein and ureter on a living donor today, so progress

 

[thedrjojo]

Depends on the program. Our residents regularly sew the portal vein and bile duct. My kidney experience I so far have only sewed the ureter, but my attending claims I get to be on the surgeon side from the beginning next case. We shall see on my living donor tomorrow...

He held up his end of the bargain, for the vein at least

 

[thedrjojo]

I heard vandy is getting a fellowship

I stand corrected, as I just signed up for the match and they are listed as a program with 1 spot...