Welcome, everyone. My name is Retta Gerges. I'm the transplant network chair of the American College of Chest Physicians, welcoming you to the part two of this webinar on training and practice opportunities in transplant pulmonology. I'd like to welcome the co-chairs of this webinar, Dr. Hakeem Asfar Ali and Dr. Gabriel Lohr. I'd like to introduce Dr. Ali, who is the lung transplant fellowship director and associate professor at Duke. Hakeem, would you like to get us started? Thank you, everybody, for coming and taking some time off today for this webinar. We have a great panel of speakers today for you, and we carry forward the discussion we started last week about pulmonary transplant training and future opportunities. So I think Dr. Lohr is professor of medicine at Baylor, and he's one of the co-chairs. So I hand it over to him, and then we'll get started. Thank you so much, Hakeem. I'm really glad that we're doing this talk. Clearly, there's a huge need for highly specialized and qualified personnel in this field, and we realized that there was not a real formal structure to some of the curriculums and some of the opportunities there. Anyone who was at the last program last week knows that we went through a list of different opportunities that there are around the country, but there's clearly more room to help develop these. So the goal of today's talks are to kind of introduce what it's like being an early career transplant pulmonologist for folks who may be interested in exploring this. And, you know, we have a wide range of speakers from early career to, I don't want to say late career, but to more senior, and a lot of great talk. So without further ado, let me start off by introducing Gloria Lee, who I have the privilege to work with, have worked with her now for five years here at Baylor St. Luke's Medical Center at Baylor College of Medicine in Houston. And Gloria's been incredible. She's one of these, she's going to talk about it, I'm sure, but was one of these rising star pulmonologists. She went through the medicine and pulmonary residency training program at Baylor College of Medicine, and then came on as the highly recruited faculty, just top of her class. We were fortunate enough to have her join us. And then she spent basically the last four years with us now as a faculty and has done an incredible job navigating the program and different changes throughout the program. So it's really great to work with her. I look forward to hearing her talk today from training to practice of transplant medicine. Thank you so much. Can y'all hear me okay? Yes. Yeah. Great. So my name is Gloria Lee, and thank you for that nice introduction, Dr. Lohr. And I love, I am really grateful for the opportunity to talk to you about my experience going from fellowship to the practice of transplant medicine. I am a native Houstonian. As you can see, I didn't travel very far for my postgraduate studies. I did my, like Dr. Lohr said, I did my internal medicine residency and pulmonary critical care fellowship at Baylor College of Medicine in Houston, where I ultimately stayed there as staff. And I will say that my passion lung transplant really developed fortuitously. When I did fellowship, my passion was in critical care. I really had no inclination towards lung transplant, just knew that it was a required rotation. And so I started the rotation, not knowing the like of transplant, but I ended that month as a first year fellow doing that rotation with an absolute passion and knew that that was what I wanted to do. I was just really fascinated with how specialized lung transplant was, but also how wide the breadth is in the sense that you still get your experience and you get your full internal medicine, pulmonary and critical care training, managing these complex patients. You see them in the inpatient and outpatient setting. You're taking care of their multiple medical problems with the help of other specialists like immunology, infectious diseases, cardiologists. While you become specialized in transplant, you do become more knowledgeable in advanced lung diseases. You become more adept with procedures, obviously. And then you still get your joy of being in critical care by helping these patients post-operatively or whenever they're critically ill within the sense of managing their ventilators and if they're being bridged on ECMO or supported on post-operative ECMO support, for example. So when I decided early on that I wanted to do transplant, I did that within my fellowship. I didn't really have the opportunity of going elsewhere for lung transplant fellowship only because my husband at that time or my husband currently, his job keeps us in Houston pretty much long term. So within my fellowship, I did six total months of lung transplant training. I did five months of cardiovascular ICU in order to get as much procedure experience as possible. I did two months of interventional pulmonary. And I aligned myself really early on with my mentor who was the program director and medical director of transplant at that time. And on my extra times, just to prove that I was enthusiastic about transplant, I did extra lung transplant clinics. I was engaged in lung transplant research and I worked quite closely with the surgeons at that time and went to a lot of procurements and observed a lot of transplants in the operating room. So my very early career, you know, was year one to two. I wasn't sure if I was committed to 100% transplant. And at that time, the opportunity was for me to do a 50% lung transplant and 50% general pulmonary, which in my personal experience, I found quite hard to balance, especially having just graduated. I didn't feel like I was really part of one group or the other, really couldn't find my niche. And I knew early on after my first year that I just wanted to do 50% lung transplant and didn't really have the opportunity or funding for them to support me at that time. And personally, also having graduated from where I trained, I struggled with having autonomy and having, you know, not feeling like a fellow. So the first two years, as most early career physicians, was a bit of a struggle. And I personally also had a very early birth of my second child and ultimately took a six-month hiatus from medicine and, you know, wasn't sure if the health of my daughter allowed me to come back. But fortunately, I did come back and I came back to a bunch of changes and obstacles, which in hindsight ended up being a wonderful opportunity for me. We had a change in medical director, our former one left to do, to pursue other endeavors. And so Puneet Garcha started his medical director role here in early 2020. We expanded our program and added a bunch of new pulmonologists. We were there for the growth of the program, and this is despite having the pandemic and all the obstacles that came with it. So here essentially is the number of transplants that we did per year at our program. And as you can see here, starting in 2014, we weren't really, we were, you know, a medium, medium-sized program. And at the time of my starting my career here, we expanded our numbers pretty significantly. In the last year, we did transplant over 70 patients. So I was, you know, really fortunate to be a part of the growth and to be, you know, to help facilitate the growth of our program. Our accomplishments as a team, you know, under the director of the leadership of Dr. Gabriel Lohr, our program is very fortunate to have the use of EVLP or ex vivo lung perfusion to expand our donor pool to ensure that all of our patients are transplanted in a timely and efficient manner. We are, we have transplanted patients for COVID-19. We were engaged in an 18 month long collaboration, a quality improvement collaboration with the Baylor Cystic Fibrosis Program to ensure that cystic fibrosis patients are adequately cared for before and transitioning to post-transplant. We have started a perioperative desensitization protocol to help our highly allosensitized patients. We have protocol in place to accept hepatitis C donors, and we have expanded our referral base. We're starting clinics in North Houston to ensure, to increase our referrals, and we're also highly engaged in clinical research as well. And I would say that none of these things happened, you know, when I was a fellow. So being able to see and be a part of the growth of our program has been a wonderful opportunity for me, which kind of leads to my personal accomplishments. You know, now that I'm at year five post-graduate, I do feel like I've gained the experience and knowledge to really adequately care for my patients, and also to be an educator to fellows, residents, and students. I played a really critical role in setting up telemedicine shortly after the pandemic to ensure that patients received adequate post-operative or post-transplant care without the risk of contracting the disease. I have expanded referrals and started seeing referrals via telemedicine. This primarily helps our patients in Louisiana who don't have a lot of options for transplant programs. Again, we are starting an outreach clinic where we are seeing patients in the greater North, greater Houston area to ensure that these patients are seen in a timely fashion. And then I've also been engaged in quality improvement in ways to, one, improve communication with referring physicians, and also we have a nice checklist discharge process in place to ensure that patients to reduce the risk of readmissions. So whether or not you've decided with last week's webinar or in ongoing, whether or not you've decided that you want to do transplant or you don't want to do transplant, my advice to you as a fellow, regardless of what year you're in, is to show up to every rotation like it's your dream job. Like I said, I showed up to my line transplant rotation not knowing anything about transplant and not even having an inclination towards it, but my enthusiasm, my work ethic really opened that door for me. I was able to find a mentor and he saw my potential and I was able to have this job and it's been a passion of mine. So you never know, but you're more likely to gain positive attention if you show interest. Read, read, read, and ask questions. Take ownership of your patients. You'd be surprised how much feedback your patients give to your staff. And, you know, just a simple, you know, if you take good care of your patients, your patients say thank you, that kind of gets you through that day-to-day grind. Most importantly also is to align yourself with a mentor. It doesn't have to be someone in transplant, but just someone that could help you open that door, remain humble, never be satisfied with what you know, and definitely keep an open mind. You know, you never know what opportunities are given to you, but stick to the opportunities that you're truly passionate about. And then my most important advice during this transition is to make sure that you have the appropriate work-life balance. When you start out as attending, you're asked to do many things like take care of patients, of course, but also engage yourself from research, education, CME, but it's important to really focus on your family, to focus on your mental and physical health. And the one thing that you don't ever want to leave behind are your hobbies. The hobbies are what gets you going through the hardest times. And then lastly, regardless of what you do, always find that passion that keeps you going. This is Jamie. She has cystic fibrosis. I've actually known her since I was a fellow when she was frequently hospitalized for cystic fibrosis exacerbation. She struggled with the decision of going through a transplant. She struggled with that transition. And so we had a lot of conversations during that time. And here she is about nine months after her transplant, she's going back to school, she's going back to the gym. And so these are the patients that, you know, we go to work for every day. And these are the patients, these are the stories that kind of really help the bad days, especially when we lose someone that we care about. So, and again, my passion also is my team. You know, my team is every member of our team, whether it's my colleagues, Dr. Lord, Dr. Shafi, Dr. Garja, our coordinators, social work, every member of our team is very invested in our program. They inspire me every day. They're my family away from from home. Sometimes I spend more time with them than my family. But these are the people that, you know, that keeps me going and keeps me inspired. And so I just want to thank everyone for the opportunity to listening to me talk. I want to thank Dr. Lord, Dr. Garja for letting me be a part of their program. And then finally, I do want to send a thank you to my former mentors, Dr. Parulakar, Kao, and Jonavalli. They're the ones that I've known since I was an intern at Baylor. And they've helped me with this to where I'm at right now. So thank you. My email address is on the top right if you have any other questions, but I'll be happy to answer them in the Q&A at the end of the webinar. Larry, that was a great talk. Hakeem, are we going to ask questions now or at the end? Yeah, sorry. We had decided to go for the questions at the end, but I don't see anything in the chat anyway. So I think we can move forward. Okay, so Gabe and I, we're going to team up for this next session. This is going to be kind of talking about building a team environment. And I'm going to just start out with some introductory remarks. And let me share my screen here. While you're sharing, I think, I don't think you need any introduction. So Dr. Girgis, for those of you, the younger fellows, is the medical director at Lung Transplantation and Spectrum Health and professor of medicine at Michigan State. And he is also the chair of the Lung Transplant Network right now. And so go ahead, Rita. Thanks. Thanks for giving us this talk. All right. Thank you so much. So I'm really excited about this webinar. I think it's a great start. I think it's generated a lot of excitement. And hopefully, we're going to be able to build on this to further advance opportunities and education in transplant pulmonology. So I have no conflicts to disclose. So what I want to quickly discuss is building the team, empowering the team, feedback and process improvement, and then the surgeon-pulmonologist relationship, which Gabe will also touch on some more. So, you know, as a, you know, I came actually to Spectrum from Johns Hopkins now almost 10 years ago. And I had to, you know, build a new program. And it was, you know, just writing down all the different people that you need is quite a long list. And they all serve really essential roles for a successful program. So you have your transplant pulmonologist. They obviously have your surgeons. And then you have your program manager or administrator. You have your nurse coordinators, both pre and post. You have your social workers, psychologists. You have a transplant pharmacist, a financial coordinator, nutritionist. You have to work with an experienced histocompatibility lab. You need a pathologist. You need other medical experts, infectious diseases, gastroenterology, cardiology, all these medical subspecialties, radiology that you're going to rely on. And then for the inpatient care of these patients, you need to have your ICU team, your inpatient nursing. And, you know, crucially in what I'm sure every transplant, every transplant knows is the importance of inpatient physical therapists and occupational therapists, speech therapists, and palliative care is also important. We have to, that they can be very helpful. And then, you know, you, every, and this is a Medicare requirement that you have to have a quality process in place. So you have typically every program is going to have a dedicated QI specialist, and you have to show that you are doing some quality project. You have your main project, as well as other parameters that you're following. And if you want to look at data, you obviously have to have a database. So you may have a database specialist. If you have clinical research coordinators or other research staff, depending on the size of your research program. And then what Gabe reminded me, and he's going to talk about more is there's totally separate teams in the operating room and anesthesia. So it's a big group and every single, every one of them is really important. So it's definitely a team now. So you got all these people on the team. And what I found is it's, you know, really important to empower the different team members. So you want to set for the entire group, a common goal and a vision for the program. Okay. You know, what are our objectives? Where do we want to see ourselves five years from now? And it's good to write down as a group, what are, what your mission statement is. So to, you know, be, just provide this life-saving therapy for your community, for your region, how do you want to do it? You know, you want to provide state-of-the-art care, compassionate care, however you want to phrase it, but good to have a mission statement that's there for everyone to see. And you want to really work on ensuring that every team member understands that they really do have a critical role to play, that we really can't do this without any particular, any, all the individuals involved, and that we're collaborating together as a group to achieve our goal and vision. And then we want to remember to celebrate our accomplishments. So the things that Gloria mentioned, you know, she hopefully celebrated that with her team. So, you know, we don't do that a lot, you know, in this, you know, at least, you know, you get, you know, people don't like, administrators, you know, don't like, you know, to pay for, you know, celebrations and dinners and things like that. But, you know, in certain, like in South Korea, it's very crucial that it's like part of your work that you go out, you go out after, out of the office with your team members to socialize. And this is very important, I think, that, you know, you see each other outside the workplace, have a drink, you know, break bread and get to know each other. And I think that this strategy, you know, giving everybody, making sure that they're critical members of the team, collaborating with them and celebrating with them encourages retention and avoids turnover. And that's a big problem in a lot of transplant programs. And this is a highly specialized area. You have coordinators and other people who've been doing it for many years. You know, they get very good at it, just like anything. And so turnover is a problem. And I think, you know, keeping people motivated and giving them a sense of importance of what they're doing will minimize your turnover. So as every day, we want to try to focus as best as possible. We're all very busy, but really important to pay attention to your team members and find ways to motivate that because everybody's working hard, everybody's busy, and everybody's got a lot of things going on in their lives. So always remember to treat members with respect. You want to show that you're open to suggestions, so you're not just, you know, barking out orders. You want to hear from people how to improve things. You want to keep team members informed about important information, status of the program. You want to respond to conflict by trying to work out solutions. Always want to find opportunities to praise your team members for doing a good job. And when something happens that is not so good, you want to provide constructive criticism. And at the same time, you want to avoid demotivating and disruptive behaviors like, you know, clarity criticisms or, you know, yelling and things like that. Obviously, we all want to avoid that. So, you know, when we talk to people during problematic situations, you know, this is from the Physician Development Program. You know, always find opportunities to praise people. So, you know, I appreciate what you did for this patient, or thanks for, you know, helping me with this project. And then when something goes wrong, you want to really minimize these criticisms. You want to avoid things like you always should do this, or you should have done it this way. Rather, you want to phrase, you know, corrective things in terms of a future request and make it a positive request. So, you know, would you do this this way in the future? And then if then requests are like, you know, so if you review this patient's medications or this patient's labs, then we then we will be able to detect this problem early. So an if then type of request in the future yields is perceived as a more of a positive thing and avoiding negative requests like, you know, don't ever let this patient's tech alignments level get too high. So there's tech, this is a lot of, there's a lot of writings about this, but ways to communicate that, that motivates your staff and encourages them to do the best work they can, because the truth of the matter is you need everybody on your team to help. And this engages them. And, and one way to do this is, is something called the Humble Inquiry is a book by Edgar, Edgar and Peter Schein. You talks about something called a here and now humility, where you are, you're regardless of status, I mean, usually, you know, you're going to be, even if you're not a medical director, when you're on rounds with a large group of people, you are the captain of the ship. And so you are going to be looked at as a, you know, and so you are going to be looked at as the leader. And you want to engage your people on your team, showing that you have a genuine interest and curiosity about what they have in recognizing, or you want them to feel that you think that they know something that you don't, or that you want to learn. And you feel that you are, that they are needed to accomplish a certain task. And so you want to hear what they have to say and show that you're genuinely interested and curious. And so he talks a lot about, you know, the asking versus telling when we're in our conversations. And finally, if, you know, as, as a medical, as a director, or even if you're not a director, you know, you want, you need to be talking to the administrators and directors, you know, because this, you know, transplant is a high, is a resource intense operation. And, you know, you got to make sure you have adequate, adequate staff to do the job, resources, space. And this is often difficult to get with tight budgets. So that, you know, when talking to managers and directors, you want to be focusing on a long-term vision. Okay, look, we have a vision in five years and we want to do so many transplants. And we need this number of personnel to get it done. And we need a quality person. We needed this database. These are things that are going to improve our outcomes and improve our volume. You want to help and phrase it in ways that come up with solutions rather than problems. And try to phrase it in a win-win situation. So, you know, if you're talking to managers and it's a budgetary issue that they're concerned, well, you know, phrase your goal in terms of that as well. You know, if we get, you know, more, another coordinator, we're going to be able to successfully do more transplants and that's going to help the bottom line. So along those lines, try to think of your negotiation as win-win for both parties. And so that's all I had and I'll leave the rest of the time to Gabe to talk about some surgical aspects. Okay. I loved hearing Ruta's talk there because I mean, I could just tell that he'd be a great person to work for. There's so many elements to this whole process. The whole, this symposium is geared towards early career development and also to fellows interested in going into transplant. And this is clearly a team-oriented and leadership-oriented specialty. Probably any aspect of medicine fits that bill. But I think that at the end of just this next five, seven minutes, I just want to emphasize how important the team component is to transplant in particular. And it's one of the things I like, and I didn't particularly, you know, play like team sports or whatnot growing up to some degree, but it's just something about it in medicine that when you pull together so much, so many different talents to achieve, really to achieve the impossible, because it's kind of what you're doing. You're rescuing some people who have no other chance at life from the brink of death many times. In fact, pretty much every time. And so it's an amazing specialty, but teamwork is a key part of it. So I'm just giving the surgeon's perspective of it. There's really, there's no point in looking at it in dichotomies. I mean, it's one big team between the surgeons and the medical docs, for sure. So if we break this down the way that I see it, you know, if you look at the Oxford English dictionary definition of a team, the team is a group of people who play a particular game or sport against another group of people or a group of people who work together at a particular job. So we think of team. A lot of times we think of teams as in sports or teamwork and obviously in day-to-day activities. So it sounds obvious, but I think that it's nice because there's a game component. It's always nice to have a fun element to what we're doing. Obviously it's extremely serious business, but in any time that you're looking at anything that resembles a competition of sorts, then you have to think, well, who is, who are you competing against? And I think that that's an important thing when you're a part of a team and you know, you're graduating from a pulmonary fellowship, you're joining a transplant program or, or your mid-career or senior career, junior career is, is just to, to remember that, that the, the enemy or the competition is certainly not anybody really on your team. And nor is it really the hospital next door or, or anything like that. It's really, it's advanced lung disease that we're, we're, we're trying to combat. And this is a formidable enemy and it's got a lot of, of unknowns. There's a lot of lack of knowledge that we have to gain in this, there's room for innovation, there's primary graft dysfunction, chronic lung allograft dysfunction, there's so many things that we have to learn to achieve to help to improve the lives of patients with advanced lung disease. But advanced lung disease is the key, really, enemy here. And so when you get together as a team in a pulmonary program, in a surgical program, it's important to, as Rita said very nicely, to have some form of a vision or a mission statement that you know where you're going, you know what you're trying to do. You know, most of us here are trying to make a better future for patients with severe destructive irreversible advanced lung disease. And so you have to work together as a team to combat that element. A lot of times it isn't that obvious and people can compete against each other or against other programs. And I think the more altruistic and the more pure your vision and motivation is, the more you're going to be able to achieve. And that's something that the earlier you learn it in fellowship or in your career, the more effective you'll be. And when you look at attributes of elite teams from Forbes magazine, everybody's seen elite teams. So we all want to be a part of a team that's going to defeat this enemy, which is advanced lung disease. We all want to be a part of something that's going to make an impact against that. We don't want to not make an impact against that. So there's many different attributes of an elite team. It's good to just have these in the back of your mind, whether it be you're looking for a job somewhere or you want to harvest some of these elements within your team. And by the way, I think I completely agree with Rita that every member of the team is a leader in the team. So in our program, Dr. Lee is the leader of that program. She's rounding and coming into contact with multiple people and anybody who's on service that particular time is the leader. The transplant pulmonologists, each and every one of them are leaders. When they're not there, the fellow is a leader. If I'm there, I might be a leader, but it is definitely decentralized leadership. So when we look at these attributes of elite teams, there's servant leadership. You really don't want to dictate things. You want to try to just provide and help the talent that you have around you. Shared vision, time-oriented, have some sense of somewhat sense of urgency in the goals you're trying to achieve, accountability. We all should be accountable to the team's success. Communication is huge. You have to communicate well, respectfully. Comfort zone expansion is an attribute of an elite team. It's an interesting concept. But I would argue that in transplant, by definition, even though we're faced every day with significant regulatory scrutiny, you have to have a sense of comfort zone expansion because that's what you're offering your patients. You're offering them state-of-the-art, end-of-life care that no one else can offer. So we have to muster up the courage to do that and have the confidence to do that. Decentralized leadership, as I've alluded to, you have to have good proper planning, after-action reviews and debriefs, and trust. You got to have a lot of trust in the team and celebrating and have a learning culture. And a lot of these things, they're not natural. You have to kind of cultivate them and develop them over time and remember them and think about them. And whether you write them down and look at it daily, but it is something that is not necessarily natural. And the flip side, and this is a great book if you haven't read it, is Patrick Lencioni's Five Dysfunctions of a Team, where he studied hundreds of high-performing teams, and he draws this analogy of a high-performing team, everyone is rowing in the same direction. So you imagine everybody rowing in the same direction, they're going to get to their endpoint a lot faster than if you have any one person rowing in the opposite direction. It doesn't really help. So the dysfunctional teams have an absence of trust. They do not want to get into any kind of conflict or question each other. There is a lack of commitment to a goal. There's an avoidance of accountability, and there's really an inattention to a goal, to where you're going to. So these are the five key dysfunctions of a team. So it's important to know this as well. You have to understand hospital cultures. As Rita mentioned, there's multiple players. And I think that this is probably, in our field, in transplant pulmonology and transplant surgery, one of the easiest things to lose sight of is that not everybody's the same. And surgeons have a certain mindset, and medicine has a different mindset. Everybody has their strengths and can view things in different ways. Most other surgical specialties, you're kind of on your own, you're performing surgery. But in this case, you are 100% dependent on these multiple different specialties. So at least from a surgical perspective, it is key to understand that not everyone is going to be like a surgeon around you. You have to be working with different cultures, different ways of dealing with problems that are many times way more effective than yours. And I think that some of the best pulmonology surgeon relationships have been ones that have been expressed a tolerance for each other, realizing that sometimes this guy's kind of over the top, but that's okay. And then vice versa. And so I think that being malleable makes for some of the best working relations in that regard. You have administrators who aren't MDs or aren't nurses. I mean, a lot of times they have a nursing background. So they're going to view things completely different than you. They're going to be looking at the financial aspect. But guess what? If you don't have someone mindful about the financial aspect of what you're doing, you can run your program bankrupt, and then you can't offer your services to other people. And some of us have MBA backgrounds. I don't, and I know a lot of ours don't. So it probably behooves us, even though we have to advocate for our patients 100%, but it behooves us to realize that there are pros that understand this from a different perspective. We have a multitude of ancillary team members, physician extenders, researchers, and the best way to interact in a team is simply to try your best to take different folks' perspectives. Teams right now, I think have, this is a book, Team of Teams, which I think is fantastic. And it was written by General Stanley McChrystal, talks about how he viewed the wars in Iraq and Afghanistan and how they had to switch from this kind of top-down leadership to command of teams, which kind of makes sense to this crazy nebulous network of Team of Teams. If you think about it, this is kind of how we function, isn't it? At least the bigger the program is, the more it starts to resemble this kind of Team of Teams concept. It's hard to get around it. And so you really have to live through values and you have to enforce certain values and attitudes throughout all the members. But at any point in time right now, whatever's happening in a particular step down ICU, there's an intensivist up there right now, there's a fellow with them, there's a resident, and they are taking care of that situation. I have to trust them and we have to respect that. Down in another ICU, it's a totally different scenario. Interoperative teams are hugely important and very easy to disrupt. And it's a sensitive infrastructure, but you have so many players, anesthesiologists, perfusionists, surgeons, residents, assistants, circulators, scrub nurse, and you have your financial leadership, your hospital administration leadership constantly regulating anything that goes on in the operating room. So it's a heavily regulated environment and it's a stressful environment. And one of the first things to do is simply to acknowledge that. We deal with life and death almost daily. And once you kind of understand that and you really start getting along very well with your team, understanding and respecting everybody, you develop much better results. And that's very important to have this dynamic interplay with all the members. In transplant, you can take a step further and you look at organ allocation teams. So we're dealing with teams on the phone all the time that are our own personal screening and management teams, OPOs, we're talking to OPOs in Alaska and Hawaii, all over the place, trying to manage donors and the processes that are going on and that are unique to their own donor hospitals. And you've got the actual procurement team, which is a huge dynamic team, multiple different organ systems being represented, each with their own teams. So, I mean, there is no greater example of teamwork, in my opinion, than you see in transplantation. And one of the most important things, Gloria mentioned this in her talk, Dr. Lee did, which is to take care of yourself. And naturally, once you've taken care of yourself, your team members, wellness is huge. Make no mistake about it. This field is dealing with the sickest of the sickest. And if it doesn't affect you, probably you're not looking at it correctly because you're telling people you can't offer them anything or you're trying your best and it fails. Thankfully, you have a lot of successes. But you have to have a way to encourage your sleep patterns, hobbies, whatever it may be, so that you and your team really take good care of themselves. And then they can each show up and be a strong member of these teams so you can achieve good outcomes. So, thanks so much for letting me chat about this. And I look forward to the incredible talks that are coming up next. All right, Hakeem, would you like to move us on and introduce Fernando? I think. Yeah, did you want? I mean, I'm sorry. Yeah, we're going to go with Deb first. Yes, please. Yeah, thanks. Thanks, Fernando. Thanks, Hakeem. All right, thanks, Gera. That was excellent. And that's what we wanted to highlight, give a glimpse of our transplant practice to the junior faculty and the fellows. And so we'll move to Dr. Deborah Levine. She's a professor of medicine and medical director at University of Texas Health. And I don't think she needs any introduction. She's been in the leadership roles in all of, in CHEST, in ISHLT, and most of the organizations that, and we've heard her great talks in almost all international conferences. Over to you, Deb. Oh, thanks, Hakeem. And thanks to you and Rena and Gabe for inviting me. This was a fantastic idea and something that's very much overdue. And I think that the transition from fellowship to getting a position and also getting a position from another position is something that is quite different in lung transplant than it is in other fields. So I think congratulations to this course and congratulations to everyone who's already given great talks. And it's a hard act to follow for sure. But today for my part, we're talking more about current and current market and future needs for healthcare professionals and lung transplant patients. So what's happening for jobs and how do we get them? Where do we go? And can you all see my screen? Yes. Okay, perfect. So our charge today is to talk about these three topics. And really, I think there's a lot of good topics that we can tease out for a great discussion at the end. So wanted to see, kind of go through these things, but also hopefully know that these are really rich opportunities for us to discuss and hear from the whole panel what they think. So we're going to talk about job availability and search, compensation and lifestyle, and then academic versus community hospital programs when you're talking about clinical transplant opportunities. So no disclosures on this topic. And I think 99.999% of us have seen this slide. And if they haven't, here it is. And you'll be seeing it a lot more probably. But this is a slide from the ISHLT looking at the progression of lung transplants being performed throughout the world. Now, obviously, this is international. But if you just look at lung transplant within the country, within the US, it's probably about 2,500 or more in terms of how many transplants are being done now. You can see that as the progression of numbers of transplants being done has occurred over really the last decade, so has the expansion of job opportunities and areas in which we can all focus on. And I think that's great. But then as this field is expanding, how do you navigate that when you're just coming out of fellowship or when you're looking for a new position? So I kind of broke it down into a few different areas. And I put down that we're going to really talk about clinical transplantation first, because I think probably 90% of us that work in lung transplant do work in clinical transplantation. But even then, it's very, very broad and really a large spectrum of opportunities, whether you work in a traditional lung transplant program or some of these other unique opportunities that are coming more and more available to us in our field. And that's because of what we just saw. The numbers are going up. The workforce is going to need to be not only increased, but expanded into different areas. So let's talk a little bit about traditional clinical lung transplantation. So if you're in a fellowship now or you're going into a fellowship, either a transplant fellowship or you're in a pulmonary critical care fellowship that you're interested in transplant, you probably have already recognized that there are, even within the umbrella of traditional clinical transplant programs, there's a ton of different models. And we are going to talk about, hopefully, all of them or touch on them so that we can have more questions about them. But the expansion of traditional lung transplant programs has occurred not only because some new transplant programs have kind of opened up or been created, but also the growth within existing programs. You can see that in the job board, there's always, hey, we need another person. We need another person. And it's because the numbers of transplants per program are expanding. And now that COVID has really slowed down, these numbers are jumping up quickly since probably the fall. So I think in traditional clinical lung transplant, there is a lot of different opportunities. In these programs, you know, traditionally, there's been a position where you are usually helping in the ICU, you're helping in the floor of the hospital, so inpatient responsibilities as well as long-term clinic responsibilities where we're watching these patients from transplant all the way through their whole journey, as well as bronchoscopies, as well as donor call and donor responsibilities. So most traditional clinical lung transplant programs give you the opportunity to really have access to all these different opportunities and work. And I think that's why we all love it, right? It's not like you're going to go to work every day and see the same thing. You're going to be rotating through every different part of the program and really become an expert in each one. So it's like many different jobs in one. And I think it keeps us on our toes. It keeps us learning. And I think one of the things about lung transplant, it's so open for so many opportunities in terms of education and learning. Every day, you're going to learn something new that you didn't know. So I think that's what a traditional clinical lung transplant program gives us, whether it's a new program or a growing program, but we're basically part of every area of lung transplantation. It gives us the opportunity to be there and learn. What about some other newer opportunities or unique opportunities that may not have been even considered 10 years ago? Well, there was a survey, a really nice survey that was put out looking at, and this was just in heart and lung transplant. What was the model that people were using for critical care perioperatively in lung transplant? Was it the pulmonologist and the surgeons that were taking care of these patients perioperatively and beyond? Was it an intensivist? Was it a critical care intensivist? Was it a pulmonary intensivist that had transplant change training? And what we found from that or what we learned from that was, and this was both in heart and lung, so not just in lung, but it was just all over the map. Every center had a different model, and that kind of mirrors what's happening in just transplant programs. You're going to find that you may see one program that you're going to be on service for six months and another that you may only do two months. So every program is different, and every program you're going to have to choose what's important to you. In terms of transplant critical care, it's just a kind of a microcosm of the whole field. And when you look at these new opportunities, there's also opportunities to be an intensivist in a multi-organ transplant center. You will be the expert not only in lung and heart transplant critical care, but also what happens perioperatively in liver, kidney, and others. So I think this is a new field, and it's actually something quite exciting. You may be asked to work in the transplant clinical care unit for part of the time, and then the other part you may just be working solely with lung transplant patients. Along with this multi-organ care, I wanted to point out that oftentimes within the traditional clinical lung transplant program and beyond, you'll be talking to other organ transplant physicians, both surgeons and clinicians, regarding, hey, I have a pulmonary or critical care problem with my kidney or liver transplant program. Can you help me? So this is another part of the position that you may say, I really like that. I like that, and I want to focus on that. So think about things that may be part of the job that you want to expand into being a unique position for what you like. And I think lung transplant actually gives you that opportunity where I think I can't think of another field that does that. You can basically really write your ticket once you find out what you like and what you're good at and what you want to focus on. ECMO, when you talk about transplant critical care or critical care in general, you know, multiple people going into ECMO as a field or to be an ECMO physician or critical care ECMO clinician really have the opportunity to combine that quite nicely with a lung transplant career. There's so many parallels and there's so many times that they overlap and interact. So consider that as a new kind of unique program that could be coming up around the country, either one or both or mixed. What about these hybrid positions that people talk about? You know, people are now building more and more of these advanced lung disease programs. They may be advanced ILD, PH, COPD, or other types of programs that within the auspices of that program, you can develop your own kind of niche. So maybe you love ILD. Maybe you love the idea of this bridge ILD to transplant. Maybe you should be an ILD and transplant physician. I mean, this is a very close relationship anyways. So it really holds a lot of the same type of patients and really is a continuum of care. What about PH and transplant? Well, that's what I like. And my PH kind of part of my life grew out of my transplant program. When I was a fellow or a junior faculty, we had like five PH patients and I asked if we could just have a small clinic with PH and that's where I learned it. And then it grew into its own kind of career as well. So I think all of these hybrid type of positions are quite frequent and they're quite popular because doing transplant, transplant, transplant, you may want another opportunity to kind of take a breather and integrate into it. So these are positions that are becoming more and more popular for many reasons. And we'll go through those as we go on. What about interventional pulmonary? Well, my fellowship, when we had my fellowship, it was a transplant IP fellowship. That wasn't a true, as we know today, IP accredited fellowship, but multiple areas of transplant, you really could use the IP training. So maybe you're an IP physician, but you want to continue with the transplant position. And I think those two as well can become part of a hybrid program. And there's way more than that. It's just that these are the things that you see most often. So these advanced lung disease hybrid transplant positions really can go, go a long way. Again, these are things that you may not think is possible, but you don't have to give anything up. You can really, again, try to navigate this so that you can go into the field you want. Remember what you start out with, with the position may not be what you end up with. And you may start off as a true, tried and true transplant only person, but kind of meld into these as time goes on based on what you like and what you find your interests are. Your interests are going to change. They're not going to stay the same forever. So again, continuing on the vein of clinical transplantation, I kind of tried to look at, you know, what are the different types of clinical transplantation? Is it, you know, in terms of places you may find a position? So the first thing I looked at was what about an academic, pure academic, traditional program versus some of these private hospital-based programs? Are they the same or are they different? Well, I think we'll see. I took, I think, five or six different characteristics and these aren't set in stone. These were just in my own mind of what I know my colleagues do and friends do from across the country. So there's no kind of reference on this. And I think as these two types of programs go forward, they really meld more into each other so that they're actually more alike than they are different. In administration, you know, in an academic program, oftentimes you have two or three bosses. You might have your hospital boss. You may have your university boss, your chair. And then you may have a transplant center boss. So it may be that you're answering to multiple different people at different times. And that's because administration is kind of an umbrella for all three tiers of your program. Sometimes it's not. Sometimes the hospital is connected to the university and everything's one. But I think this is something that is comparative to some of the private programs where you do have one kind of CEO or medical director of the program, not of the transplant program, but of the hospital. And really you're one-stop shopping. You need something, you go to that person and oftentimes it's a little bit more of a straight shot to the top. So that being said, I've never worked in this program and I think those that have can actually talk to us a little bit more about that. But this is one of the ways that these two programs may differ. Compensation. You know, when I first started thinking about this, when I knew I was going to give the talk, I was like, well, academic programs are basically more RBU-based and bonus-based, whereas private programs are not. But when looking into it in more depth and kind of doing my own mini review or mini survey, I found out I was completely wrong, that they are so much alike. So private programs and academic programs all can work on a salary-based compensation or RBU or mixed. Most of them have bonuses and the bonuses are set up per program, not by academic or private, but each program does something different. And most of the time there's some kind of combination of above. And I've seen it in both the academic program and the private program. And I think that's one thing that you should look at when you're talking about how am I going to be paid and how is my salary going to be provided to me. It's super important because there are multiple parts to this. Again, this type of thing, when you look at it, this type of my lecture could be looked at in almost any pulmonary job. But the things that are different about lung transplant is there are things that we do that may not be compensated for by an RBU or salary position. Donor call, for example, may not be compensated at certain universities. Maybe it's part of the job. Maybe some of the reviewing of labs on Saturdays or some of these things that may be extra or what we call extra compared to other specialties in pulmonary critical care. These are things you want to ask about. And these are the things that you want to know about prior to really finding the job that is best for you. Practice style. Again, when I started looking into this, I thought they were quite different. But really, when Dr. Lohr and Dr. Grugas start talking about team-based practices, really, they both all involve team-based practices. I think there's not really a true private practice lung transplant program because it is team-based for all the reasons that they really so well elucidated in the prior lecture. What about job description? Again, I think this is something really important and really can't be differentiated between academic and private. It really goes program to program to program. How is my time spent? How much clinical time is spent? How much time do I have academic duties and administrative duties or bronchoscopy? So everything can be negotiated, but you have to figure out where you start and what you want. So looking at the job description, kind of time distribution of your responsibilities is super important when you're asking about what I need. Size, again, variable, variable, very, very large academic programs and very, very large private programs. So again, do you want to work in a smaller program where maybe there's a smaller team and you have time to do other things, for example, other hybrid disease states? Or do you want to be in a very large program doing very, very high numbers? Again, these are things that change over time. You may start off at the small program and they become very large or vice versa. So kind of looking at where you want to start, knowing that that could change very easily and very quickly. Resources, again, important to find out where am I getting my resources? Am I going to be able to get these things that we need as a team? And I think, again, where resources come from, again, depend on the program, not so much of whether it's academic or private. So I think even though clinical transplantation can be divided in academic and hospital-based programs, you also have to remember they can be very, very unique even within those definitions. What about other job availability or some type of other positions? Well, beyond clinical transplantation, there's many, many ways that you can go. Even if you do a transplant fellowship and you say, I've done a little bit of clinical transplantation, I love it, but I want to do something else. Well, it's either even the right one. You graduate or later on in your life, think about all the opportunities. And there's so many. I think with COVID and things that we've been through the last two or three years with everyone in pulmonary critical care, people are looking what other things are available to us. And so I think it's good to look at it now when you're a fellow or right after fellowship or before your transplant fellowship to say, what do I want to focus on to begin with, knowing you can change if you need to. So beyond clinical transplantation, you might already be in a situation where you've done a lot of bench research. You might be an MD PhD. You might've really focused your career on bench research. What about translational research? Same thing. You may be wondering how you can work with the basic scientists to bring things to fruition through translational science. It's a great opportunity and it can be a kind of a wing off your clinical position. And then clinical research, it doesn't have to be a whole job. It could be part of your position. How much time do you get? What is it going to take for me to get that? How do you write grants? All of these things are things that you want to know from your position or the people offering you a position, where these things stand, what's available to you, and how you can advance if you want in these separate categories. What about industry jobs? Well, industry is just not pharmaceuticals anymore. It's devices, it's diagnostics. There's many, many areas that you may look at, and it may not be in a lung transplant position. It may be in a transplant company, or it may be in a different lung company. But the training you get with lung transplant kind of makes it very, very... You have a very big opportunity because you've learned so much through the science. The science can really help you in industry positions. Because not only do you go through things in terms of immunosuppression, but you also look at antibiotics and also other types of new drugs and new devices. Administration. Usually when you think of administration, you think about someone who's a CEO or in business, but think about a transplant administrator or things like that, that as you move up, you can consider getting some other alternate degree. I think Gabe might've talked about an MBA. A lot of people look into MBAs just for their position in transplant, but it also helps you if you want to kind of veer off into that portion of transplant. It's still a very big part of transplant, and oftentimes it's open to us in terms of what we want to do. Yes. Okay. Compensation and lifestyle. Again, very wide spectrum of position. You want to know from your position, do you have service time or off service time, and understand the compensation model. I'm going over time, so I'll go a little faster now. How do I get there? Well, all of these things are based on how you can talk to your mentors, mentors outside your program, to find out ways of getting there. Again, remember that transplantation is a combination of multiple areas. We won't go through these because I'm talking a lot longer, but I think that these are some self-reflections to ponder. You may want to take a picture of this and look into really, how does this field fit into my lifestyle? How do I fit into the environment? What do I need to get there? What skills do I want? What skills do I need? Really, what is the best for me? Remember, choosing a position is a process. It's not one decision. It's really a lot of different decisions that will make a big impact on you and on your happiness. Remember, all these little decisions are best bets along the way. You really need to know what you can and cannot do. Really, think about what you want to do a majority of the time. Sometimes you're going to have to do a little bit other stuff too, but what will make you happy a majority of the time? Choose what is meaningful to you. In general, be open to all possibilities. Trust your instincts. Figure out what you want and what you don't want. Remember, really only you know yourself. Basically, you make a decision based on what you know about yourself as well as the opportunity. Again, there's no mistakes. Nothing has to be permanent. At the end of the day, when I wake up and go to work, what excites me about going to work that day? Really, at the end of the day, no matter how we do it, our goal as transplant physicians is taking care of patients in many different ways. Thank you, and I hope I didn't go over. Thanks. Bye. Thank you, Deb. That was a very motivating talk and despite running over, but that's okay. We're a little bit short on time, so we'll move on to our next speaker. Now, we should have a few minutes at the end for some questions. It's my pleasure to introduce, last but not least, Dr. Fernando Torres, who is a professor of medicine at University of Texas Southwestern in Dallas, where he's the medical director of the lung transplant program and head of the pulmonary hypertension unit. Fernando is another old-timer. We've left the, you know, Gabe mentioned the old-timers. We left the three of us to the end, but I've known Fernando for a long time, and thank you, Fernando, for taking the time to join us. He's going to be talking to us about outreach or the role of community pulmonologist in lung transplant medicine. Hi, Rita. Thank you, guys, for inviting me to talk about lung transplantation and the role of the referring physicians, etc. So, I started doing lung transplantation as a fellow. I did two years of fellowship at University of Colorado. I finished there, and then I came to UT Southwestern, where I became a lung transplant physician part-time, private practice part-time, lung transplantation, and then after five, seven years, I became the medical director of the lung transplant program, and 100% dedicated, 90% dedicated to lung transplant, about 10, 20% to pulmonary hypertension. So, having said that, over the past 10 years, I have developed a lung transplant program where we started doing about 15 transplants a year when I took over the program, and now we are somewhere between 50 and 70 transplants a year. So, I wanted to talk first about building a lung transplant program, the need of the community, the hospitals for the university support, then developing a network. There are different types of networks that we need to talk about, a healthcare system network versus outside referrals network, and each one will behave a little bit different, and we will have to deal with them differently, and then we have to put goals, and then we have to monitor how we achieve those goals, and then react to them over time. So, the community, when we are building a lung transplant program, the first thing that we have to think about is what are the transplant centers in the region, how many transplants do they do, and are they meeting the need in the community for the number of patients that are there? For example, when I started doing lung transplantation and took over the directorship at UT Southwestern, we were having more deaths in the wait list than we were transplanting, so I felt that that was a problem. Why is it that this is happening? We were not providing or fulfilling the need in the community to do lung transplants, and that was a problem we had to address that with the community, and then how satisfied is the community with the pulmonologist and the medical team, the transplant team, with the service that we're providing as a transplant center, and that's extremely important because you need the trust of the referring physicians that their patients are well cared, and that you are serving in their best interest. Otherwise, and that relationship will start to deteriorate to the point where you are not going to get those referrals in the future. As we build the lung transplant program, you have to get the hospital support, and what am I talking about? Well, you need an intensive care unit. What kind of support are you going to have in that unit? The number of beds, the nursing staff to help you with those patients. You are going to have a floor and telemetry unit. How many patient beds am I going to have? Am I going to have a core of nurses that are going to be taking care of my patients, or they're going to be a free-for-all out there? You're going to have to deal with the operating room if you're a surgeon because how many am I going to have availability to do my surgeries whenever donor is available, et cetera. In addition to all of that, you need education. You need to be teaching the nursing, the respiratory therapists, the dietician. When Dr. Giergis was talking about all these multidisciplinary teams, you have to educate them. It's not just I'm here and suddenly all the team members are going to be able to take care of your patients. That's not how it works. All of these things are not in place. It's going to affect those referring doctors and referring patients to your center. The physicians, you don't only have to educate the transplant pulmonologists and surgeons. Then you have all that multidisciplinary teams of cardiologists, GI doctors, nephrologists, et cetera. They all have to be in sync. If they are not in sync, your program will not succeed, and suddenly you are not going to be successful. Your survivals will get affected. Your referring doctors will notice. Then obviously you are going to be working, like Dr. Levine was talking, a university system or a practice system. You are going to need help with salary support, coverage, et cetera. Just keep that in the back of your mind that you cannot run the whole show and you depend on other people. As Dr. Levine was talking, remember there are many things that we do that are not covered by that RVU system. If you don't have any ways of subsidizing all that time, you are going over time to not be compensated adequately. Over time, you realize that you are underpaid and that will bring problems down the line. But as I was talking before, you need to develop a network, a referring network that is going to send patients to your center. The healthcare systems, if you have a network of hospitals that belong under one umbrella, then the referring physicians is a little bit more simple because the patients are driven by their insurance towards the center. It's a little bit simpler in that flow of patients. But having said that, you are going to need to talk to those physicians who are going to be referring patients to you because at the end of the day, they may opt out of sending the patients to your center, even if you are in the same healthcare system. So, communication with the referring physician is key and keeping those lines of communication, keeping those referral lines working appropriately is extremely important. Now, when we're talking about outside referrals, outside of your network, then things become a little bit more challenging. Why? Because there's not that mandate or that easy transition of patients from the community to the center. So, building those referral lines is harder and it will require outreach efforts. Those efforts can be on CME, it can be going and visiting physicians, it can be by doing outreach clinics. But at the end of the day, you are going to have to commit a lot of time in building those relationships in the community. Again, another part of what Dr. Levine was talking about that this is not something that generates an RVU. So, you have to keep that in the back of your mind. There are a lot of things that we do that it has nothing to do with the RVU process. But just by having processes in place doesn't guarantee success. So, you have to have systems in place to monitor your success. For example, every month I get these types of reports from my administration. How many lung patients have been referred to the clinic? How many patients we have added to the wait list? How many patients have been evaluated and how many transplants have we done? In order to achieve all of that, in our case, we built outreach clinics. So, we have five outreach clinics throughout the North Texas area. And obviously, all these places were selected by looking at the marketing, looking at how many patients each area have, how many patients have a center nearby that they will go to that other center, etc. And over time, it took about six months to identify those five spots throughout the North Texas where we did the satellite clinics. But just having those clinics doesn't mean success. So, we monitor how many patients have been referred to the clinics, how many patients have been evaluated, how many patients they have ended up in a waiting list, and then how many patients have been transplanted from those satellite clinics. As we move towards telemedicine, then what's the reach out from our clinics? So, even though we have a patient, an outreach clinic in Amarillo, patients are coming from Kansas all the way to that clinic in Amarillo. Now with telemedicine, it's a little bit easier. You can do it from the home base. But as the telemedicine slows down, we may have to go back to those cities and fly over there, and then patients will drive to those outreach clinics to be evaluated, be seen, and then being considered for lung transplantation. It's important to remember all of these patients are referred to that clinic by a referring physician. So, communication to those referring physicians of what are the patients that you are looking for, and what are the things that need to be addressed prior to a patient via a lung transplant clinic, a lung transplant candidate are important, and we have to identify those qualities and make sure that you're referring physicians so that they don't, the expectations of them sending a patient to you meet what they're going to be referring back, meaning the patient is overweight, they knew beforehand the patient was overweight, and that's not a surprise, etc. This is an example of one of the satellite clinics, Midland Satellite Clinic, where we have referrals, and we monitor that over time, and we see how many evaluations, how many patients are added to the wait list, and how many transplanted. And then over time, we decide if that clinic is providing these, if we're providing enough help to the community for us to be going over there and providing that service. So, also we look at the volume of those clinics, and we monitor how many clinics are we doing virtually, how many are in person. We look at metrics. We have to know that a patient that is satisfied will communicate to the referring physicians to tell them, yes, we have a good experience there, thank you for referring us to that center. Phone access, how easy it is for a patient to call and answer and have their needs answered. How fast are we getting the patients into the clinic or answering their phone calls, making appointments? We monitor the press games, no-shows, how fast we answer their refill medications, etc. For example, phone access, and you can see over time that for me, our phone access has been going up and down, and a lot of times it requires going back to our phone service people and saying what's happening, that we have 4% abandonment rate on phone calls, etc. We put metrics, and if the phone people are not achieving those metrics, then we go back to them and make them answer questions, etc. A lot of times it's, oh no, we have turnover and we are understaffed, etc., and the administration needs to know that, so they go back and help them hire more people and retain the personnel. We look into how easy it is to contact the lung transplant clinic, etc., and we put benchmarks throughout it. What I'm trying to say is not as simple as saying, let me open a lung transplant and boom, I'm here open for business. There is a lot of things that you have to put in place so that your center is successful, and I'm trying to show you all the metrics that we at UT Southwest have followed, but there are so many other metrics out there that you can be following and monitor to make sure that everything works well. Here I'm showing the, answering the referring physicians or the patient within one day or five days from being contacted, etc. We also monitor the volumes, how many patients are being seen throughout the clinic, all those outreach links, plus our home base, the mothership, how many encounters are being done person versus telemedicine, how responsive we are, how many refills our nurses are doing, are they doing it on time or not, how often our nurses are responding to the telephone calls, how easy it is to the patients getting into the telehealth. So we do many different QAPI projects throughout the program, all of them because we have to keep the patients pleased and we have to make sure that we are pleased, we are able to have an engaged patient and an engaged referring physician so that the patients communicate back to the referring physicians, telling them how good of an experience they had when they came to UT Southwest so that then your referring physicians feels comfortable sending more patients to our centers. Again, we have subcommittees looking at different metrics throughout the year and sometimes those metrics change, they're fluid. We can concentrate on clinic flow one year and the next year, concentrate on wait time for seeing a provider and we monitor that and all of these metrics, stress gain scores, we send them back to the physicians so that the nurses, so that they know how their group is doing and also individually, how each individual nurse doctor is doing. For example, how the nurses are, how is it that the patients feel that the nurses are doing and they give us a score and we have benchmarks for that and we are below that benchmark and we try to coach that particular nurse and find out how they're doing it and why is it that they're not achieving our metric goal that we have in place. The same thing with physicians. Experience in clinic, how easy it is to move through a clinic and sometimes the scores drop and we have to find out, oh, it's just because we're making construction, so now it's difficult for patients to get in and be seen, etc. All of those things are kept in factor for when we are doing all of this. Fernando, can we try to wrap up so we get just a couple minutes for questions? We are almost there. So we look at the telemedicine and we follow all of this, how easy that the telemedicine is working and the main important thing is that you have to monitor the progress, you have to monitor how you have done and make sure that your efforts were efficacious and that you have to remember that the referring physicians, if you do not have them on board, then your transplant program is not going to be successful. Remember, they are going to be not only important to help you when the patients are living far away because they can do testing, initial testing over there, and then send the patient back to the home base and help you manage the patient pre-transplant as well as post-transplant. Thank you, guys. Thank you, Fernando. That was very, very impressive. I'm really impressed with the amount of metrics that you're following there. That's great. So we're short on time, but we did have a question earlier that I want to get to in the chat, and the question is related to specific training programs. I don't know if Deb is still on, she may not be, but are there specific training programs that formally offer these combined approaches to training like the advanced lung disease, and can you suggest some specific institution's training programs? Also, do you think there's demand for combining roles, or do some centers just want you to wear one hat like the PH person versus the ILD person versus the transplant pulmonologist? Anyone want to take that question? Sure. I think, again, I can take a shot at that. So as far as the training programs go, that's one good thing, as we discussed in last week, too, that there is a lot of leeway in pulmonary transplant fellowship programs, that they can actually be tailored. And like in our program at Duke, we usually ask the fellows what their interests are. So we kind of, in addition to transplant, some do pulmonary hypertension, some do ILD, and there are some who do cystic fibrosis. So it depends on the interest. We kind of mix the clinics for them and some inpatient service so they can keep their other interests and get trained in them as well. And I think most programs, there are about 10 or 11 programs that we have for transplant, most of them are flexible in doing that. And as far as the other part of the question, combining roles, I think, and Rita and Fernando and Gloria, you guys can jump in. I think it also depends on how busy the program is. A lot of the programs, like if they do 100 transplants or 150 transplants, then, you know, it is busy. So for a medium-sized program, I think most of the pulmonologists that I know do have some additional ILD or participation in the advanced lung disease programs. Yes, depending on the program that you join, the needs for that program can vary. For example, when I came in to UT Southwestern in Dallas, there was no one in North Texas who was managing pulmonary hypertension patients. So I remember vividly being asked, can you build a pulmonary hypertension clinic? And I looked at them and said, as long as I've never called the pulmonary hypertension man in Dallas, I'm okay with that. And look at me, I became a big guy in pulmonary hypertension in North Texas. So it depends on the needs of the area, the size of the program, all of those will tend to shape your job. For example, right now we have eight physicians in the lung transplant team, none of them, except me, do anything but lung transplantation. But five, seven years ago, you know, I was doing half pulmonary hypertension and another one of the physicians was doing some ILD, etc. So it depends on the size of the program. I would suggest to you, try to start just transplant and then leave yourself open later on to add stuff to it. It's very easy for you to add things, extremely difficult for you to take off things. Meaning, if you are hired to do lung transplant plus ILD, it will be very difficult for you to give away that ILD later on. While if you're doing lung transplant, then you say, hey, I'm having a free time, I want to do ILD, piece of cake. Everybody will allow you to do more. Excellent. Any other questions or comments? I don't see any other questions in the chat. All right. Well, Gabe, would you like to make some closing comments? Yeah, I just, I hope that, you know, everybody walks away with a clear message that lung transplant is a growing field. There's a huge market for it. Going into it makes a huge impact on patients' lives. It gives you an incredible niche that is highly valued at most, if not all, academic institutions around the country and even in many instances around the world. So it's a very exciting time for lung transplantation. We need people to be going into it. We need junior career people to continue to succeed. And it's just been great hearing all these talks and being a part of this webinar. Thanks, Rita. Thanks, everyone. That was fantastic and very motivating. And I think we really hope that we can build on this going forward. So thanks, everyone, for taking time out of your busy day and have a great evening and hope to see everybody ISHLT and then certainly Nashville in October. Please join us at our network meeting for more information. Thank you. Thank you, guys. Thanks, everyone.

transplant pulmonology

training

job availability

compensation

lung transplant procedures

teamwork

communication

traditional clinical transplant programs

intensivist positions

hybrid roles

expansion of lung transplant programs

community support

program success