Career in transplantation offers unique rewards, challenges

Issue: April 10, 2013

ByWilliam Wood, MD

William Wood

I recently returned from the annual “Tandem” transplant meetings in Salt Lake City.

The program, which serves as the US update on the field, is co-sponsored by the American Society for Blood and Marrow Transplantation and the Center for International Blood and Marrow Transplant Research.

The theme of the meeting was somewhat bittersweet. Two of the giants in bone marrow transplantation — E. Donnall Thomas, MD, the founder of the field, and Karl Blume, MD, the former director of the City of Hope and Stanford University programs — died within the past year.

However, their legacy is a vibrant and still-growing field, with increasing numbers of autologous and allogeneic transplants performed worldwide for broadening patient populations and indications.

With this increase in transplant volume has come a recognition by the field that many more physicians will be needed in coming years to keep pace with the expected demand. Thus, the National Marrow Donor Program’s System Capacity Initiative seeks, in part, to understand why physicians in training might or might not choose transplant as a career, and how more might be brought into the field.

As I think about my own career — now only 2½ years old following my fellowship — I’m happy with the professional choices that I’ve made, and I can think of many reasons why others should think about doing the same. I know there are other trainees who read this column — I was a fellow when I started writing it — and I thought I would take the rest of this space to write about why this is a great field.

‘Something for everyone’

Patient care.

The physician-patient relationships in this field are powerful and long-lasting. Patients come to us with life-threatening diseases. Although the future after transplant is uncertain, it is filled with hope, representing a chance to cheat cancer and resume a normal life.

This is alluring and even dangerous because successes are intensely gratifying, but the power of false hope can lead to tragic consequences. This, in turn, imbues the clinical decision making before and after transplant with profound significance.

The number of visits and amount of cumulative time spent with patients undergoing care of the highest complexity allow providers to know their patients very well. Whether the outcomes are good or bad, the journeys are shared, and this is rewarding.

Clinical complexity.

I was initially attracted to the field because I loved internal medicine as a resident. The clinical care of transplant patients requires knowledge in a vast array of areas, and it demands constant critical thinking. All manner of malignant and nonmalignant hematologic diseases come to transplantation, requiring familiarity with the behavior and treatment of each.

The safe management of patients in the early and late post-transplant periods necessitates knowledge of infectious, gastrointestinal, pulmonary, cardiac, endocrine, neurological and other issues. This is challenging but exciting.

Immunobiologic innovation.

The field of transplantation is paradoxically growing while fundamentally imperfect. Where the field has come since the early proof-of-concept days decades ago is remarkable — from 90% mortality rates initially to >50% cure rates of previously incurable diseases. However, 20% to 30% of allogeneic transplant patients still succumb to treatment-related mortality. Graft-versus-host disease is common, and it still is not separated biologically or clinically from graft-versus-tumor tumor effects. This means the field is constantly innovating within and across transplant centers. The opportunity to witness the frontiers of clinical immunology, and to think of new ways to make the procedure safer and better, is unique in medicine.

Research opportunities.

Research in stem cell transplantation spans the spectrum of basic, translational, clinical, psychosocial and health services research. The quality-of-life questions are among the most interesting in medicine. Outcomes researchers increasingly confront important questions around cost-effectiveness and diffusion of technologies. Thoughtful clinical trial designs are required to answer questions asked in an environment of small sample sizes and biological heterogeneity. The insights from translational and basic science researchers are readily applicable to many other areas of cancer medicine. There is something for everyone, regardless of background or interest.

Attracting trainees

When I was a fellow, I was initially scared off by a commonly held misconception that barriers to entering the field were insurmountable. The Systems Capacity Initiative is actively working to address this.

Within the next year or two, a variety of educational modules will be on the Web and available to students and residents, explaining in accessible ways the background and basics of clinical transplant medicine. Although the learning curve is steep, the material can be assimilated — with planning — over the course of a hematology/oncology fellowship.

Almost everyone in the field, myself included, is accessible and eager to reach out to and mentor interested trainees. It is certainly possible to collaborate with others and present transplant-oriented research during residency and fellowship. The barriers are not nearly as high as one might think.

I believe that we will be able to meet the challenges of a growing transplant population and increasing workforce needs over the years ahead, but we’ll need help. I would be happy to talk with anyone who is thinking about doing this as a career to offer strategies and insight. Stem cell transplantation isn’t a perfect practice, but working together, we can make it better.

For more information:

William Wood, MD, is an assistant professor of medicine in the division of hematology/oncology at the University of North Carolina in Chapel Hill. He also is a HemOnc Today Editorial Board member. He may be reached at UNC Health Care System, Division of Hematology and Oncology, 101 Manning Drive, Chapel Hill, NC 27514; email: william_wood@med.unc.edu. You also may follow him on Twitter (@WoodBD).

Disclosure: Wood reports no relevant financial disclosures.