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In View: People in Transplantation

Bethany Foster, MD

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doi: 10.1097/TP.0000000000004122
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You attended McGill for a Bachelor’s in Science and went on to get your MD from the University of Ottawa. Has it always been clear to you that you wanted to have a career in Medicine?

BF: Not at all. When I started my undergraduate degree, I really had no idea where I wanted to end up. In fact, I can recall when a high school friend suggested that I consider medicine, I dismissed the idea. I was very interested in science—physiology in particular—but did not have a clear plan. It was only once I started my undergraduate studies and looked around at what other students were planning that I realized that maybe medicine would be a good option for me.

You did a Masters in Clinical Epidemiology and a Research Fellowship in Pediatric Nephrology at the University of Philadelphia. How did this training influence your career trajectory?

BF: I cannot overstate the impact on my career of the 3 y I spent at Penn exclusively dedicated to research training. The MSc gave me the foundations I needed to pursue epidemiologic and clinical studies. But it was really the time spent pursuing patient-oriented research, doing statistical analyses, and learning to write papers and grants in Dr Mary Leonard’s laboratory that made the difference. The mentorship and sponsorship offered by Mary were also critical. She was instrumental in getting me involved in clinical practice guideline committees and introducing me to all the key international players in pediatric nephrology.

Most recently, you graduated from the Telemachus Scholars Program at McGill that focuses on innovative small group mentorship. What have you learned? Should those programs be more widespread and be a firm component of faculty development? How would you describe your mentoring style?

BF: The Telemachus Scholars Program is an innovative faculty mentoring program developed in the Faculty of Medicine at McGill and initiated in 2017.1 This program brings together faculty members from different departments at different career stages with comparable academic profiles. This program not only taught me how to be a better mentor but also provided me with mentorship. I learned that we all need multiple mentors—and that more junior faculties have a great deal to offer to more senior faculty. The small group model of mentoring provides multiple points of view to both junior and senior participants and is energizing. I think other centers would definitely benefit from a similar program.

My mentorship style is collaborative and supportive. I depend on mentees to let me know what type of support they are looking for, but at the same time, I am available to provide suggestions and feedback. I’m a born editor, so I am also quite ready to review grant applications and manuscripts, providing feedback and helping to improve their work. I also try to be a sponsor—that is, to introduce young trainees and investigators to colleagues in the field, help catalyze collaborations, and give mentees opportunities to speak, write, and participate.

You have been critically involved in the leadership of the Research Institute of the McGill University Health Centre. Can you share achievements and challenges of this institute?

BF: The Research Institute of the McGill University Health Centre (RI-MUHC) has been through enormous changes since 2013. Following substantial administrative reorganization, the institution underwent a major physical move in 2015, relocating 3 of McGill’s teaching hospitals to a new, single campus and fully integrating the former Research Institute of the Montreal Children’s Hospital into the larger RI-MUHC. The move was largely successful, and the new facilities are beautiful, with access to state-of-the-art equipment, dedicated research space, and highly qualified personnel staffing our research platforms.

Investigators at the RI-MUHC have been very successful at attracting research funding. The physical location, housing all members on the same campus, has promoted new collaborations and interactions that were not considered in the past.

Like many similar institutions, space for growth is a perennial challenge. Perhaps our most pressing challenge is achieving a more complete integration of pediatric- and adult-oriented research. There is so much potential for innovative science when the perspectives of child health scientists and developmental biologists are combined with those of scientists focusing primarily on fully developed humans. We have much to learn from each other, so we are actively working toward improving our integration.

You have been the Chair of the Department of Pediatrics at McGill since 2021. How do you manage your teaching, clinical, and research responsibilities?

BF: Well, as I answer this, I have only been in the role for just >5 mo, so it is the early days! I try to block 1 d/wk for research-related work—with mixed success. It seems like there are endless administrative tasks to distract me! Like most researchers, evenings and weekends are my most productive writing times.

I have been very fortunate to have developed highly productive collaborations with more junior investigators—which has really been a win-win. This has been a great way to keep doing research while supporting the careers of junior investigators with outstanding potential.

I had to cut back a lot on my teaching responsibilities but still give some lectures to students and residents. I have also reduced my clinical load a bit since taking over as Department Chair.

You have been academically most productive. What publication are you most proud of?

BF: That is a really tough question. I guess if I had to choose one, it would be my 2011 article “Association between Age and Graft Failure Rates in Young Kidney Transplant Recipients.”2 I actually did not even really want to do this study because I thought we all knew the conclusion before starting (which it turns out we did)! Nevertheless, it was a really important article for a number of reasons. First, this was the first study to actually demonstrate that graft failure rates are higher in adolescence and young adulthood than in any other age interval, regardless of age at transplant. It sounds silly, but I think this article helped to remind people that pediatric transplant recipients will all be adolescents someday, and they will also have high risks when they enter this life stage. Second, the approach we took in this study, treating age as a time-varying variable, is an approach we have used in almost all subsequent analyses. This approach was also instrumental in our novel studies identifying differences in graft failure rates by recipient sex.3 We were able to show that sex differences in graft failure rates are age-dependent—and in opposite directions in children and young adults compared with older adults. I’m not sure we would have discovered this had we not done that 2011 study.

You have a strong interest in pediatric transplant nephrology. How have long-term outcomes for pediatric patients changed over time? What have been critical improvements?

BF: Long-term outcomes have improved over time, although the pace of improvement may be slowing in recent years. The most recent study of which I am aware that specifically addressed this question was published in 2014.4 American pediatric kidney transplant recipients showed an approximately 5%/y decrease in both mortality risk and graft failure risk between 1987 and 2012. The greatest improvements were seen in the first posttransplant year, with more modest improvements in subsequent years. Interestingly, females showed a slightly (but significantly) smaller improvement over time than males. It is difficult to know from observational studies that specific factors were responsible for the improvements. Improved surgical techniques, more potent immunosuppression, better methods of antibody detection, and improved prophylaxis and treatment of infectious diseases likely contributed to the improvements. It is possible that better coordination of multidisciplinary care may also have played a role. It is very encouraging that outcomes have improved; however, we need to continue to try to optimize transplant care to further improve outcomes. One way to do this is to target high-risk periods like adolescence and young adulthood to identify the mechanisms driving higher failure rates and optimize therapies. Another approach is to focus on groups for whom improvements have been less striking to understand why they have not experienced more improvement and to intervene to change this.

Sex- and age-specific outcomes have been another recent interest. What are driving components of this interest?

BF: One of the things that drew me to pediatrics was the fact that the period from birth to young adulthood is marked by enormous change. Of course, adults also experience important physiologic changes with aging, although these are less commonly considered. These normal age-related differences need to be taken into consideration when studying disease states. The poorer outcomes in adolescent and young adult kidney transplant recipients are typically blamed on poor treatment adherence. But age-related differences in immune potency should also be considered and investigated.

In much of my earlier work assessing graft outcomes, we noted poorer graft outcomes in young females than males. These were children and adolescents, so we knew that this was not due to pregnancy-related sensitization. After I started studying medication adherence, we observed better adherence in young females than males. That is what really got me wondering what was going on. If females really had better adherence but worse outcomes, then we needed to determine what biological mechanisms could be playing a role. I guess I have also been struck by the fact that there is a lot of talk about “personalized medicine,” where treatments are guided by the genome, but very few treatments are guided by sex or age. Sex and age are easily measured (for free!) and may have incredibly important effects on many biologic functions—including immune function. These observations drove me to investigate the interacting effects of age and sex in transplantation.

You are the Co-Chair of the Women in Transplantation Initiative in The Transplantation Society. This is a wonderfully structured and very well-organized effort. Can you share some of this group’s achievements and goals?

BF: I first got involved with the Women in Transplantation (WIT) initiative at a strategic planning event in 2017. Many important leaders in transplantation were there, including Kathryn Wood, Megan Sykes, Lori West, Elaine Reed, Roslyn Mannon, and others. In 2017, the organization decided to expand its goals and split into 2 “pillars.” Pillar 1 continues to focus on the original WIT goal of promoting and supporting the careers of women working in transplantation. Pillar 2 focuses on promoting research into issues of sex and gender in transplantation. WIT has organized successful networking events at dozens of transplant and immunology conferences over the years and has participated in the organization of interesting scientific sessions at The Transplanation Society, American Transplant Congress, and other conferences. Last year, WIT launched the first annual grant competition to support research trainees studying issues of sex and gender in transplantation. WIT has also launched a third pillar, which will focus on advocacy and addressing sex and gender disparities in organ donation and in access to transplantation.

We hope that there is a little time left for you to do things outside of your professional life. How do you enjoy your spare time?

BF: I like to spend as much of my spare time outside as possible. In summer, I cycle, swim in lakes, and hike. In winter, I get out every weekend I’m not on call to cross-country ski (or, as my kids used to call it, “uphill skiing”). I also enjoy reading fiction.

REFERENCES

1. Mortaz Hejri S, Steinert Y, Elizov M, et al. An interdisciplinary peer mentoring program for faculty members. Med Educ. 2021;55:1331–1332.
2. Foster BJ, Dahhou M, Zhang X, et al. Association between age and graft failure rates in young kidney transplant recipients. Transplantation. 2011;92:1237–1243.
3. Lepeytre F, Dahhou M, Zhang X, et al. Association of sex with risk of kidney graft failure differs by age. J Am Soc Nephrol. 2017;28:3014–3023.
4. Van Arendonk KJ, Boyarsky BJ, Orandi BJ, et al. National trends over 25 years in pediatric kidney transplant outcomes. Pediatrics. 2014;133:594–601.
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