Membership and Professional Standards Committee Consider Primary Transplant Surgeon Requirement- Primary or First Assistant on Transplant Cases Membership and Professional Standards Committee

What problem will the proposal solve? Primary transplant surgeons for abdominal organs must have performed a set number of transplants and procurements as the “primary surgeon or first assistant” No specification about the number of cases performed as the primary surgeon Concerns that abdominal surgeons could qualify with only “first assistant” experience Responsibilities of a surgical first assistant vary across institutions May have never performed critical surgical transplant functions expected of a primary transplant surgeon OPTN Bylaws require that primary surgeons at kidney, liver, and pancreas programs must have performed a set number of transplants and procurements as the “primary surgeon or first assistant.” Because there is no specification regarding the number of cases performed as the primary surgeons, concerns have been raised that applicants could qualify with only “first assistant” experience. Because surgical first assistant responsibilities vary across institutions, there are concerns that a primary transplant surgeon could be approved that may never have performed the critical surgical transplant functions that would be expected of a primary transplant surgeon leading a designated program.

What are the proposed solutions? Training Pathways Fellowship program accepts a case towards completion of training = OPTN accepts the case towards key personnel requirements in Bylaws Abdominal and thoracic primary surgeons Clinical Experience Pathways At least 50% of the cases cited in an application must have been performed as the primary surgeon or co-surgeon Applies to primary kidney, liver, and pancreas transplant surgeons Bylaws already require a set number of primary surgeon cases for thoracic primary surgeons; this proposal does not impact those requirements To address these problems, the MPSC is recommending one approach for the primary surgeon training pathways in the Bylaws and another approach for the clinical experience pathways. For all training pathways in the Bylaws, both abdominal and thoracic programs, if a transplant or procurement is counted towards the completion of fellowship or residency training then that case will also count towards the key personnel requirements in OPTN Bylaws. To validate these training experiences, primary transplant surgeon applicants applying through one of the fellowship or residency pathways will be required to provide a copy of the operative log from their training. For the clinical experience pathways, the MPSC recommends adding a new requirement that at least 50% of the cases cited on a primary transplant surgeon application must have been performed as the primary surgeon. This new requirement only applies to the primary kidney, liver, and pancreas transplant surgeon clinical experience pathways as the Bylaws already require thoracic primary surgeons to have completed a set number of cases as primary surgeon. This proposal does not impact those Bylaws as they have not prompted any known issues.

Supporting Evidence Proposal stems directly from recommendations developed by a Joint Societies Working Group (JSWG) Collaborative effort between the American Society of Transplantation (AST), the American Society of Transplant Surgeons (ASTS), the North American Transplant Coordinators Organization (NATCO), and the MPSC Training Pathways Fellows are always noted as an assisting surgeon on hospital billing records OPTN Bylaws training pathways for primary transplant surgeons already rely on quality training and experience gained during fellowship or residency Clinical Experience Pathways Qualifying without some primary surgeon transplant and procurement experience is unreasonable JSWG agreed that at least half of cases cited should have been performed as primary surgeon MPSC indicated “co-surgeons” are common in abdominal transplants, and such cases should be viewed as equivalent to cases performed as primary surgeon The recommendations included in this proposal were discussed by a Joint Societies Working Group, and are representative of a collaborative effort between AST, ASTS, NATCO, and the MPSC. Regarding the proposed changes to the fellowship pathways, discussion of this topic highlighted that fellows are always noted as an assisting surgeon on hospital billing records. Because of this, and considering that the OPTN Bylaws training pathways already rely on quality training and experience gained during fellowship or residency, the MPSC agreed with the Joint Societies Working Group that the best and easiest solution would be to allow all experience that counts towards the completion of one’s transplant training to count towards OPTN primary transplant surgeon requirements. Regarding the clinical experience pathways, the Joint Societies Working Group agreed that it would be unreasonable for a primary abdominal transplant surgeon to qualify with only first assistant cases. To address this, the Joint Societies Work Group and the MPSC agreed that performing half of the required cases as the primary surgeon was a reasonable threshold. When the MPSC discussed the Joint Societies Working Group recommendations, they also indicated that “co-surgeons” are common in abdominal surgeries, and such experience should be viewed as equivalent to cases performed as the primary surgeon.

How will members implement this proposal? No immediate action required of members Membership applications received on or after the implementation date will be evaluated in consideration of these new requirements Primary surgeon applicants applying through a training pathway must provide a copy of their fellowship or residency operative log. Kidney, liver, and pancreas primary surgeon applicants applying through clinical experience pathways must have performed at least 50% of cases as primary surgeon or co-surgeon. No action will be required of members upon the implementation of these proposed changes. These proposed change will not impact current primary transplant surgeons; only membership applications received by UNOS on or after the implementation date will be evaluated in consideration of these new requirements. At this time, primary transplant surgeons applying through a training pathway will also be required to provide a copy of their fellowship or residency operative log. For kidney, liver, and pancreas primary surgeon applicants applying through a clinical experience pathway, at least 50% of the reported cases must have been performed as the primary surgeon.

How will the OPTN implement this proposal? Board consideration- December 2016 Programming – No Federal government must approve updates to membership application forms Implementation- MPSC will evaluate membership applications in consideration of these new requirements Transition- changes do not impact current primary surgeons New requirements will be used to evaluate applications received on or after the implementation date If public comment is favorable, this proposal is slated to be considered by the OPTN/UNOS Board of Directors during its December 2016 meeting. Assuming the Board adopts these changes, they would be effective pending federal government approval of updates to the membership application and notice to the membership. No programming is necessary to implement these changes. There is no monitoring associated with these proposed changes. After implementation, primary transplant surgeon applicants that do not meet these new requirements will not be approved. So all are clear, let me reiterate that this new requirement does not impact current primary transplant surgeons. These new requirements will be used to evaluate primary transplant surgeon applications received on or after the to-be-determined implementation date. That being said, if an application is submitted after the implementation date the proposes someone who is currently a primary surgeon, for example, to form a brand new liver program, then that applicant will be reviewed relative to these new Bylaws.

Specific topics for feedback Should the recommendations in this proposal also apply to the primary intestine surgeon Bylaws requirements approved by the OPTN/UNOS Board of Directors in June 2015 that are pending implementation? Should the recommendations in this proposal also apply to the surgeon requirements of the pediatric component Bylaws approved by the OPTN/UNOS Board of Directors in December 2015 that are pending implementation? The MPSC is particularly interested in the community’s perspective on whether these changes are appropriate to apply to Bylaws that were recently approved by the Board and are pending implementation- primary intestine transplant surgeon requirements and the pediatric component Bylaws. Because previous public comment discussions about these Bylaws included concerns about the ability to meet the case volumes required by each proposal, the MPSC was hesitant to apply additional requirements without more feedback from the community.

Questions? Jeffrey Orlowski, MS, CPTC Committee Chair Jorlowski@lifeshareok.org Chad Waller Committee Liaison chad.waller@unos.org