1 Renal Transplant Unit, Section of Surgery, Division of Transplantation, European Union of Medical Specialists, Fondazione Policlinico “A.Gemelli,” Catholic University of Rome, Rome, Italy.
2 Section of Surgery, Division of Transplantation, European Union of Medical Specialists, University Hospital Marques de Valdecilla, University of Cantabria, Santander, Spain.
3 Section of Surgery, Division of Transplantation, European Union of Medical Specialists-European Board of Surgery Hammersmith Hospital, Imperial College, London, United Kingdom.
Received 21 August 2015. Revision requested 15 November 2016.
Accepted 30 November 2016.
The authors declare no funding or conflicts of interest.
J.R. led the efforts in initiating, designing and drafting of the article. D.C. and V.P. contributed with edits, comments, and revisions.
Correspondence: Jacopo Romagnoli, MD, PhD, Renal Transplant Unit, Università Cattolica del Sacro Cuore Fondazione Policlinico Gemelli Largo. A. Gemelli, 8 (9th floor) 00168, Rome, Italy. (Jacopo.Romagnoli@unicatt.it).
Transplantation surgery, although established more than 60 years ago, has not lost its complexity, challenge and fascination. Unlike any other field, transplantation offers a successful treatment for many end-stage organ diseases in a multidisciplinary approach. Worldwide, more than 100 000 solid organ transplants are performed every year with 80 000 kidney, 24 000 liver, 6000 hearts, 4000 lungs, and 2500 pancreas transplants. Although numbers have increased steadily, the availability of organs is only satisfying less than 10% of the global needs.1 Transplant surgery does not only come with surgical complex procedures and treatments but also with a working schedule that is not always predictable. Although quality of life aspects may not be perfectly lined up in transplant surgery and have deterred some from choosing the field,2 there is an obvious and unique gratification from patients experiencing the gift of life, in addition to an exciting field of clinical and experimental research. Career aspirations of potential transplant trainees revealed that only few envisioned practicing transplant surgery long-term and many did not want to apply for transplant surgery positions only, however, preferred practicing transplant surgery in parallel to a second specialty.3 At the same time, surgical trainees appreciate training programs with an exposure to transplant surgery and the participation in donor runs with a unique anatomical experience.4 Although the fascination for transplant surgery continues on many levels, many trainees are deterred from choosing this field as the intensity of on-call commitment, and the heavy workload may impact on their quality of life. There is also concern that transplant surgery training in Europe has not been structured, an additional aspect that may deter surgeons from the field.2
In Europe, transplant surgery has been practiced without a broadly accepted curriculum over decades by many excellent surgeons that had been board certified in general, vascular, gastrointestinal, hepatobiliary surgery, or urology, frequently combined with an unstructured learning by doing approach in transplant surgery.
It has therefore become evident that a structured educational pathway reflective of the field's complexities and multidisciplinary character with a European-wide recognition will be necessary allowing a seeming-less migration of transplant surgeons between member countries. Moreover, transplant centers providing this training need identification and recognition.
The European Union of Medical Specialists (UEMS) has a longstanding experience in assessing quality of medical training based on accepted standards. With a mandate of the section of surgery in the UEMS, the Division of Transplantation had been established in 2007 and charged to establish state-of-the-art standards in the care of organ transplantation in Europe that include highest-quality training programs.
The Division of Transplantation had been instituted subsequent to deliberations of the Transplant Working Group as part of the Section of Surgery, in the UEMS with the input of the European Board of Surgery (EBS). The Transplant Working Group included representatives of each member state nominated by the respective national professional medical organizations in official communication with the UEMS/EBS.
Members of the Transplant Working Group had been charged to produce a report including: (i) the current status of training and accreditation for transplant surgery in each member country, (ii) existing opportunities for training at the graduate and postgraduate level, (iii) the identification of key transplant centres providing the expertise to offer accredited training, and (iv) opinions and suggestions on minimum requirements and structure for accreditation.
Based on this analysis, it became evident that most European transplant surgeons received training without any formal structure. Sweden represented an exception with young surgeons receiving training in an officially recognized structured pathway.
This analysis provided a great opportunity for a joint collaboration of the Division of Transplantation, national transplant societies, and the European Society of Organ Transplantation appointing now 2 permanent council representatives to the Division of Transplant Surgery.
Training standards have been recommended to the UEMS and the EBS. Moreover, health authorities, national and international transplantation societies have been encouraged to establish and to accept the standards of professional practice in transplant surgery. The line of communication for the Division of Transplantation includes the General Secretary of the UEMS, the Section of Surgery, the Executive of the UEMS, the Commission of the EU and the Advisory Committee for Medical Training.
A main achievement has been the European Diploma of Transplantation Surgery, certifying transplant surgeons based on UEMS standards and principles in all European countries. The first examination had been offered during the 13th European Society of Organ Transplantation Congress in Prague and the number of participants has been progressively increasing. The examination consists of different modules (multiorgan procurement, kidney, pancreas, liver) and candidates can apply for 1 or more modules depending on the field for which a certification is warranted.5,6 The multiorgan donor module is considered a prerequisite for subsequent organ-specific modules.
As of October 2016, 264 transplant surgeons have received the Diploma of Fellow of the EBS Transplantation. At the same time, 196 senior transplant surgeons (70% serving as department chairs/division chiefs) have received the Diploma on an Honorary basis. Of note, although the majority of applicants have been board-certified/specialized surgeons in EU member countries, an increasing demand from applicants outside of the EU (eg, South America, India, China) has been observed.
Of interest, the UEMS Diploma is increasingly considered as a prerequisite for junior faculty positions in Transplant Surgery, and we expect that the examination will become mandatory in the foreseeable future. Based on the positive experience in transplant surgery, other divisions within the UEMS Section of Surgery (for example the Division of Hepatobiliary Surgery) have now implemented comparable programs.
Ways to prepare for the diploma have also been established and include a syllabus containing topics and all requirements requested for the examination, preparatory courses aimed at presenting the format of the examination to potential candidates, and online educational material.
Moreover, a robust qualification process has been established for the accreditation of transplant centers offering training in Transplant Surgery. Subsequently, several centers have successfully obtained the accreditation (Goteborg, Essen, Groningen, Oslo, Budapest, Rotterdam); others have applied and the accreditation process has been initiated.
Collateral effects of our activities have also fostered the introduction of other board exams including the European Board of Transplantation Medicine certifying transplant physicians across Europe. In addition, the European Transplant Coordinators Organization in collaboration with the Board of Transplant Coordination and European Transplant Coordinators Organization has been provided with a framework for a board examination, currently in its sixth edition. Finally, in 2012, The European Board of Transplant Immunology had been established with the aim to promote the highest standards of training and education for transplant immunologists working in the field of Histocompatibility and Immunogenetics. Most recently, the Division of Transplantation has reached out to the American Society of Transplant Surgeons (ASTS). Common interests of UEMS and ASTS in education, training and quality assessment have been defined and delegates of the ASTS participated and observed 2015 UEMS Diploma.
In summary, extensive and thorough deliberations in the Division of Transplant of the UEMS have resulted into a high-quality and accepted board examination for Transplant Surgery. This examination is recognized by all EU member countries and will facilitate the mobility of transplant surgeons in Europe. Moreover, expert Transplant Centers in Europe have been accredited for the education of transplant surgery fellow, a process that is expected to include the majority of established transplant centers in Europe in the next years.
The authors are most appreciative to colleagues and national delegates in the Division of Transplant Surgery, UEMS for all their hard work and support during the last 10 years making this dream come true: Jan Lerut, Xavier Rogiers, Paolo Muiesan, Ferdinand Muelbacher, Gabriela Berlakovich, Stefan Schneeberger, Jacques Pirenne, Branislav Kocman, Leonardo Patrlj, George Kiriakides, Vassilis Hadjianastassiou, Nikos Kessaris, Milos Adamec, Martin Oliverius, Allan Rasmussen, Krister Hockerstedt, Helena Isoniemi, Bjarne Kuno Møller, Virge Pall, Rene Adam, Karim Boudjema, Benoit Barrou, Francois Rene Pruvot, Wolf Otto Bechstein, Bjorn Nashan, Andreas Paul, Michael Mitsis, George Glantzounis, Laszlo Kobori, Imre Fehervari, Eytan Mor, Hadar Merhav, David Hickey, Umberto Cillo, Marteen Sloof, Robert Porte, Jeroen Dubbeld, Frank Dor, Per Pfeffer, Aksel Foss, Tim Scholz, Zbigniew Wlodarczyk, Vitor Ribeiro, Jorge Paulino Pereira, Irinel Popescu, Mihai Lucan, Frantisek Hampl, Ratislav Kunda, Radoslav Kminiak, Valentin Sojar, Fernando Pardo, Annika Tibell, Michael Olausson, Lars Wennberg, Pierre Alain Clavien, Philippe Morel, Markus Weber, Thierry Berney, Osman Abbasoglu, Sadik Ersoz, Darius Mirza.