Training Experiences of American Society of Transplant Surgeons Fellows in Deceased Donor Organ Procurement

Safe and efficient deceased donor organ recovery is paramount to success in solid organ transplantation. A core training mission of the American Society of Transplant Surgeons (ASTS) is to ensure that graduates of accredited transplant surgery fellowships achieve competence in multiorgan procurement. Despite the importance of sound technique in organ recovery, training paradigms across fellowships are not well defined or described. Currently, formal educational requirements are limited to 2 short videos within the core curriculum available through the ASTS Academic Universe and performance of 25 multiorgan procurements.^1,2 To our knowledge, no additional, standardized curriculum has been implemented to teach this skill.

To characterize current training models and trainee comfort in multiorgan procurement, we administered a cross-sectional survey, in the spring of 2019, to all current ASTS fellows and ASTS member surgeons who had completed fellowship in 2017 or 2018. Respondents answered objective questions and also provided qualitative feedback on training program strengths and weaknesses.

Surveys were distributed to 182 current fellows and recent graduates with a 38% response rate. Respondents were predominantly male individuals, aged 30–40 years, and represented all United Network for Organ Sharing regions. Most performed multiorgan procurements independently during their first year, after 15 or fewer proctored cases. Only 19% received formal didactic curricula about organ procurement as part of fellowship training. Most felt comfortable performing brain dead liver and kidney donor operations before independence, but only 65% felt comfortable with pancreas procurement. Volume and instruction in donation after circulatory death (DCD) and pancreas donors varied widely. Fifty-two percent of respondents performed 10 or fewer DCD procurements, and only 65% of respondents procured a pancreas graft independently during fellowship. Eighty-one percent of respondents felt the pancreas was the most difficult organ to assess for transplant suitability (Table 1). Several themes were evident from the free-text responses. Strengths included fellow autonomy and fellow-to-fellow instruction. Weaknesses included absence of faculty oversight and formal didactic education and perpetuation of bad habits through fellow-to-fellow teaching. Finally, lack of donor pancreatectomy and DCD experience were cited as major deficiencies.

TABLE 1. - ASTS fellowship trainee survey results

Question	Response (n = 69)	Number (%)a
Age (y)	25–29	1 (1.43)
	30–34	19 (27.14)
	35–40	40 (57.14)
	41–50	7 (10.00)
	Not reported	3 (4.35)
Gender	Female	24 (34.29)
	Male	44 (64.29)
	Not reported	1 (1.43)
Region of fellowship training program	Region 1	2 (3.23)
	Region 2	9 (14.52)
	Region 3	5 (8.06)
	Region 4	4 (3.23)
	Region 5	9 (14.52)
	Region 6	1 (1.61)
	Region 7	11 (17.74)
	Region 8	5 (8.06)
	Region 9	5 (8.06)
	Region 10	6 (9.68)
	Region 11	2 (3.23)
	Canada	5 (8.06)
Year of first independent procurement	Year 1	47 (90.38)
	Year 2	5 (9.62)
No. of procurements performed before independent procurement	0	1 (1.92)
	1–5	3 (5.77)
	6–10	12 (23.08)
	11–15	16 (30.77)
	16–20	10 (19.23)
	21–25	4 (7.69)
	>25	6 (11.54)
Presence of formal didactic education during fellowship	Yes	12 (19.35)
	No	50 (80.65)
I felt adequately trained to perform the technical aspects of the procurement procedure before my first independent procurementb	Liver: strongly agree or agree	47 (90.38)
	Kidney: strongly agree or agree	48 (92.31)
	Pancreas: strongly agree or agree	34 (65.38)
No. of DCD procurements performed (proctored and independent) in fellowship	0	3 (5.17)
	1–5	16 (27.59)
	6–10	11 (18.97)
	11–15	6 (10.34)
	16–20	9 (15.52)
	21–25	3 (5.17)
	>25	10 (17.24)
Who taught the DCD donor operationc	Senior fellow	26 (44.83)
	Attending transplant surgeon	31 (53.45
	Physician assistant/surgical tech	7 (10.45)
	Nonaccredited transplant fellow	0 (0)
	Other	1 (1.49)
	Did not perform DCD procurement	2 (3.45)
Independent DCD organ procurement during fellowship	Yes	49 (84.18)
	No	9 (15.52)
Independent pancreas procurement during fellowship	Yes	33 (63.46)
	No	19 (36.54)
Have you ever felt unsure about your ability to assess the quality of an organ in situ?	Yes	33 (64.71)
	No	18 (35.29)
During independent procurements as a fellow, which organ or organs do you find, or did you find, to be the most difficult to assess quality or suitability for transplant?c	Liver	14 (26.92)
	Pancreas	42 (80.77)
	Intestine	4 (7.69)
	Kidney	0 (0)
	None	3 (5.77)

^aVaried response numbers are due to missingness.

^bQuestion answered on 7-point Likert scale with following answer possibilities: strongly agree, agree, somewhat agree, neither agree nor disagree, somewhat disagree, disagree, and strongly disagree.

^c“Select all that apply” question.

DCD, donation after circulatory death.

Although limited by a relatively low response rate and potential for bias through overrepresentation of certain regions, our results demonstrate significant variability in multiorgan procurement training and education across ASTS-accredited programs. Respondents felt adequately prepared to perform brain dead donor hepatectomy and nephrectomy, but educational deficiencies existed in DCD and pancreas donor experience. Furthermore, few fellows received formal multiorgan procurement didactics, and fellow-to-fellow instruction was the prevalent training model. These findings suggest an opportunity for an ASTS-led educational quality improvement effort. A standardized, hands-on curriculum, with a competency-based assessment and certification pathway, could be developed to ensure uniform skill attainment for all fellows. A mandatory workshop for first-year fellows at the existing ASTS Comprehensive DCD Workshop, with creation of a similar, simultaneous pancreas donor workshop, could provide a potential platform to institute such a change.³ Regardless of the approach, a thoughtful adjustment of current fellowship training paradigms should be considered, especially in light of national efforts to increase organ availability through broader sharing and utilization of marginal organs.