Medical Students: Career Profiles
Dr. Alexander Wiseman - Transplant Nephrologist
The clinical "sub-subspecialization" of transplant nephrology evolved in response to the growing success of the field of kidney transplantation and the inevitable need for physicians who could focus specifically on the unique issues of the immunosuppressed patient. Kidney transplant outcomes have reached success rates of 90-95% at one year following transplant, with longer-term (10 year) graft survival approaching 50%. Given this success and growing numbers of patients requiring long-term management, the Organ Procurement and Transplant Network/United Network for Organ Sharing (OPTN/UNOS) was contracted by the Center for Medicare Services (CMS) to set minimum experience requirements for Medical Directors of kidney transplant programs. Over time, the American Society of Transplantation and the American Society of Nephrology developed specific fellowship curricula and accreditation programs that emulated these requirements in order to ensure adequate numbers of well-trained individuals who could meet the growing needs of transplant programs. At present, this entails a one-year fellowship for board-certified/board eligible nephrologists (for most, this usually follows the second or third year of general nephrology fellowship training). Those who complete training are competitive for positions in academic transplant programs, hospital-based kidney transplant programs, and within private practices that maintain large numbers of transplant patients in follow-up. This training can be combined with research-based training both in the clinical and basic science areas.
An informal poll of the day-to-day life of a transplant nephrologist would reveal an in-depth application of immunology, nephrology, and general internal medicine with strong elements of ethics in medicine. Applying immunology is a daily practice, with interpretation of HLA testing, crossmatch results, and post-transplant manipulation of antibody- and T cell-mediated injury using proven and novel immunosuppressive strategies. General internal medicine principles of cardiovascular risk assessment and management, endocrinology (diabetes, bone disease, lipid management), infectious disease, and malignancy risk combined with the interplay with these risks with immunosuppression lead to unique presentations in the transplant recipient requiring management by a "sub-subspecialist". The risk of recurrent glomerular disease and immunologic injury requires cutting-edge knowledge of genetic, immunologic, and metabolic diseases related to kidney disease. Lastly, the ethical issues of transplantation, beginning with a the concept of rationing a scare resource (organ donors), to the health and welfare of living donors, to the ongoing debates of payments to donors and the methodology of "donor swaps" when immunologic incompatibility prevents a willing and able donor from donating to a loved one, make the day-to-day life an exciting, intellectually challenging field. As the ultimate reward, the patients who receive kidney transplants are truly transformed and (for the most part) motivated and dedicated patients, and the success of medical science that transplantation represents is something to appreciate every day.
From a quality-of-life perspective, there is significant flexibility for the transplant nephrologist, not only in job description but also in the work-life balance. The academic transplant nephrologist may spend 25-75% of his or her time in direct patient care, with the remainder spent in policy development (OPTN/UNOS), research (examples include outcomes research from large and local databases, basic immunology research, and translational research), and educational efforts locally, nationally, and within transplant organizations. Clinician-educator positions are common in transplant nephrology given the growing need for expert management of a unique patient population. Outside of academic medical centers, many opportunities exist in Transplant Centers that are managed by private hospitals and large nephrology groups. Job opportunities are more geographically limited than general nephrology practice since most Transplant Centers are in larger metropolitan areas. Often the workday is primarily clinic-based and involves working prominently as the leader of a multidisciplinary team of social workers, nurse coordinators, pharmacists, financial coordinators, and dieticians in collaboration with transplant surgeons. While dialysis and "on-call" activities still exist, they generally are less than other nephrology professional tracks. Compensation is often not based on dialysis income, but usually is recognized by the Transplant Center as a critical value and is typically supported by hospital support and/or nephrology group support to at least equal levels of general nephrology income.