EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Key words : Administration, Advocacy, Clinical innovation, Emerging pathways, Ethics, Research

Introduction
In medicine, good medical leadership is critical to delivering high-quality care to patients.¹ This entails stepping away from one’s day-to-day clinic work and individual physician-patient relationship and examining problems at a systems level.² There is a growing body of evidence that suggests that physician engagement in leadership leads to better delivery of care.^3-5 Building physician capacity for leadership is crucial for the advancement of knowledge, understanding, and wisdom in medicine.²

Despite this, many physicians do not know how to engage as a leader, and those practicing clinical medicine do not think of themselves as leaders.⁶ Currently, there is not much offered in the form of training and education to trainees in leadership.^1,2,7 Many presume leadership entails “taking official positions of authority.”8 This pertains to the big “L,” that is, taking formal positions in senior leadership teams, such as ministries and professional societies, or the little “l,” that is, something more fine-grained and local.⁶ However, the true meaning of leadership is envisioning a preferred future and influencing the activities of an organized group toward this vision.^2,9 It can entail different pathways and does not necessarily constitute being in charge of one’s program.

Transplantation is a unique field of medicine that entails the application of ethical norms to social practices and requires greater accountability and transparency than most other fields of medicine. In addition, there is a scientific component to progress and development, and clinical practice is inherently multidisciplinary and collaborative. Thus, effective leadership is key to the continued growth and success of this field. However, although many want to engage and be more involved, how to embark on a path of leadership is a challenge for some. This paper proposes 6 potential pathways to consider while embarking on leadership in transplantation and presents some other emerging pathways to consider (Figure 1). The profiles of some of the major leaders in the field of transplantation are highlighted to exemplify them. Last, how to choose from these pathways is described.

Six Potential Pathways on Leadership in Transplantation
1: Clinical innovation
The first, the most difficult, and the most important pathway to leadership in transplantation is clinical innovation. This entails introducing new diagnostic and therapeutic methods into clinical practice and is not to be mixed with experimental care.¹⁰ Innovation usually entails newly accepted and experimental methods whose efficacy has been demonstrated, but, because of lack of experience, methods of application and precise indications for use remain to be specified.¹⁰ This is a unique pathway to leadership and can sometimes lead to one attaining a legendary status in the field.

Dr. Joseph Edward Murray, a Nobel Laureate exemplifies this. He discovered how rejection following organ transplant in humans could be mastered, and he successfully transplanted a kidney between homozygous twins for the first time.¹¹ He pioneered transplant of kidneys obtained from deceased donors.¹¹ Other examples of clinical innovators include Dr. Thomas Starzl who performed the first human liver transplant and has often been referred to as “the father of modern transplantation.”¹² Other examples include Drs. Christiaan Barnar and Norman Shumway for pioneering adult human-to-human heart transplant and Dr. Magdi Yacoub for introducing advanced innovations such as the heterotopic “piggyback” heart transplant and the domino heart-lung/heart transplant procedures.^13-15 One need not be a surgeon to be a clinical innovator in transplantation as the field requires discoveries and innovations in immunology and pharmacology. The most important profile to highlight here is that of Dr. Paul Terasaki who introduced the microcytotoxicity test for detecting anti-HLA-antibodies, HLA-typing, and for crossmatching.¹⁶

2: Research
The second and perhaps the more common pathway to leadership in transplantation is via research. Scientific research entails applying systematic and constructed scientific methods to obtain, analyze, and interpret data.¹⁷ Scientific research can be classified according to the data collection techniques based on causality and relationship with time and the medium through which they are applied or according to their descriptive or analytical features.¹⁸ Studies based on national registries and other administrative data sets are quite popular in transplantation and have helped answer challenging questions often not otherwise possible in the field of organ transplantation.¹⁹

There are innumerable individuals to highlight here, and the author chose some of her personal inspirations. First is Dr. Dorry Segev, who is known to be one of the top researchers in transplantation.²⁰ He has published extensively on a range of issues such as kidney exchange, desensitization, long-term donor risk, access to transplantation, and posttransplant outcomes. Other key researchers include Drs. Akinlolu Ojo and Robert Wolfe for their work in demonstrating the survival benefit of transplant and describing the risk of kidney failure in non-renal solid-organ transplant, Dr. Bruce Kaplan for his work in immunosuppressive pharmacology and transplant outcomes, and Dr. Kim Solez for his contributions to the Banff classification. Many more prominent researchers are known to be inspiring and impactful leaders in transplantation.

3: Education
The third pathway to leadership in transplantation can be via education. Within this, there are two arcs to consider. First is trainee education. Teaching future health professionals is critical to maintaining a future workforce, and teaching is an essential part of clinical practice in academic hospitals. One can be involved in undergraduate, graduate, or postgraduate training as well as faculty development programs. Progressive leadership roles to pursue have been well summarized by Coe and colleagues.21 Profiles to highlight are those of Dr. Velma Scantlebury (associate dean for community education at the University of South Alabama), Dr. Alfred Kow Wei Chieh (assistant dean of education at the National University of Singapore), Dr. Natasha Ali (associate dean of continuing professional education at the Aga Khan University of Pakistan), Prof. Didier Sameul (dean of the faculty of medicine at Paris Sud), and Dr. Mahmoud El-Meteini (former dean of the faculty of medicine at Ain Shams University in Egypt).

Another fascinating arc to leadership in education in transplantation is via patient and public education. Public education on organ donation and explaining the social significance of organ donation is key to increasing the deceased donation pool.²² Enhancing the educational process is thought to be key to increasing living donor comprehension, optimizing informed decision-making, and ultimately increasing transplant procedures.²³ Several transplant leaders have undertaken this pathway to leadership. This includes Dr. Amy Waterman who is trained in social psychology and has developed fascinating educational programs for patients and potential donors.²⁴ Another profile to highlight is that of Dr. Marcelo Cantarovich who is leading several educational efforts on organ donation and transplantation for schools, health authorities, and nongovernmental organizations.²⁴

4: Administration
Another important pathway to leadership in transplantation is via administration. This is an important role where one is tasked with developing administrative policies to organize the program and to develop the overall mission and mandates in an interactive and highly regulated health care environment.²⁵ Empirical research has suggested an association between the ranked quality of a hospital and when the person running it is a physician.⁴ Because physicians are clinical and content experts and know the core of the business, they can make effective administrators to establish and run a transplant program.

This has been an important pathway for many and can be critical to establishing or developing transplant programs in regions where they did not exist before. Prof. Mehmat Haberal exemplifies this pathway to leadership. He established the first hemodialysis center in Ankara, Turkey, the Middle East Dialysis and Organ Transplantation Foundation, the Middle East Society for Organ Transplantation, and the Turkish Transplantation Society.²⁶ Dr. Nancy Ascher, the chief of transplantation and chair of surgery, was critical to building a liver transplant program at the University of California San Francisco,²⁷ as were Dr. John Dossetor to the transplant program at McGill University,²⁸ Sir Terence English to the heart transplant program at Royal Papworth Hospital,²⁹ and more recently Dr. Tshali Iithete to the transplant program in Namibia.³⁰

5: Advocacy
Another great path to leadership in transplantation is via advocacy. This entails contributing one’s expertise and influence to improve health and to support the mobilization of resources to effect change.³¹ Transplant professionals are uniquely positioned to function as public advocates for health as they understand the medical aspects of issues better than any sector of society.³² Many enjoy access to policy makers and leaders and thus possess a great deal of leverage in influencing public processes and priorities.³²

An inspiring profile to highlight here is that of Dr. Robert Montgomery who has been an advocate for high-risk transplants such as incompatible transplants and those from hepatitis C-positive donors. He wrote an inspiring piece outlining his own journey to receiving a heart transplant from a donor with hepatitis C.³³ Dr. Arvinder Soin is another transplant surgeon who is taken up an advocacy role in increasing transplants and tackling COVID-19 misinformation. He has a strong social media presence and often shares beautiful and humane stories on living donation. Dr. Elmi Muller is another example who is known for her advocacy work for patients with HIV-related nephropathy and pioneered HIV positive-to-positive organ transplant.³⁴ Several professionals have been involved in advocacy related to organ trafficking and transplant tourism in varying capacities.³⁵ Many more have taken lead with respect to addressing racial-, sex-, gender-, and age-related disparities in access to transplantation.

6: Ethics
In the field of transplantation, medical ethics values that incorporate systematizing, defending, and advocating concepts of right and wrong conduct related to organ donation are of extreme significance to the field.³⁶ Ethical frameworks that include the complex network of patient, donor, and organ are key to the progress of transplantation. Some of the earlier ethical issues were related to the definition of death and organ procurement. The Ciba Transplantation Conference and the Harvard Medical report in the 1960s led to vigorous debate among ethicists and legal scholars regarding the definition of death.³⁷ In the 1980s, governmental agencies got involved in examining the ethical, social, and economic aspects of organ procurement.³⁸ Even as recent as 2012, ethical and policy considerations in organ donation after circulatory determination of death were being continually developed.³⁹ Several other issues require strong physician leadership, such as financial incentives versus neutrality, implicit versus explicit versus presumed consent, and commercialization of organs.³⁶ The gap between the demand for organs and the supply of organs has not diminished; in fact, it has widened in several regions. As unique ideas are introduced to address this, ethical issues will continue to emerge, and physicians will need to lead the ethical arguments and generate the frameworks within which to operate. Currently, many transplant leaders are collectively taking charge of a range of ethical issues, such as organ trafficking, financial neutrality, social media use, drug coverage, and living donor care.^35,36,40-42

Emerging Pathways in Leadership
Quality improvement is an emerging field to leadership in medicine. It entails systematic and disciplined ways to eliminate waste from processes, improve outcomes and experiences for patients, and eradicate mistakes.⁴³ This is a largely unexplored pathway in transplantation. Leadership in information technology is another pathway with limited uptake thus far. It can entail improving patient access to reliable health and disease management information and outcomes reporting to empower patients to enter treatment outcomes data.⁴⁴ Classifiers based on artificial intelligence to address different aspects of organ transplantation are emerging, and physician leadership is definitely needed in this field.⁴⁵ Given the importance of social media in the current age, leadership in social media, such as via an ambassador program as developed by the European Society of Transplantation, is another emerging pathway to leadership in transplantation. In addition, as patient-reported outcomes are being increasingly recognized as an important health measure, patient engagement in research via various mechanisms is another emerging pathway to explore (Figure 1).⁴⁶

Implications
It is important to mention that these proposed pathways are meant to serve as a guide on where to start but are interdependent. Some of the best clinical innovators mentioned above were the top researchers and administrators of their time. One may start with one pathway and be led into others as expertise is built upon and new experiences are created. For example, Prof. Mehmat Haberal’s profile was highlighted under administration, but he has also established leadership in advocacy and education. This is the case for almost every individual mentioned above. Thus, while one can start with one of the above-proposed pathways, opportunities are often generated that expand one’s leadership profile in several other domains.

The pathway to start with can be chosen using several techniques. Several courses on leadership start with an exercise on self-reflection to assess one’s goals, strengths, and weaknesses. Critical reflection practices are important to leadership development.⁴⁷ A constructivist approach can enable one to build on previous experiences of leadership and to incorporate new learning.⁴⁷ In addition, one ought to consider the supply and demand principle and explore opportunities within a program where there is a need for leadership. This may ensure more support and help from the program. Strong mentors, coaches, and sponsors can also help with self-reflection and better direct future leaders toward such opportunities.²¹ They can help increase skills, can orient one to the institutional/program’s culture, and can overall align one toward the individualized vision or goals.²¹ Advice and mingling with a formidable network of peers may also help direct the pathway to pursue while fostering successful career development and vitality.⁴⁸ Participating in leadership programs, such as the emerging leaders program from the International Society of Nephrology, can help dissect one’s capabilities and skills.

Conclusions
This paper summarizes several pathways to leadership in transplantation. The list is comprehensive but not exhaustive. Good leadership is needed in transplantation and requires foresight, perseverance, and commitment. As medical professionals who have dedicated years to learning and training in transplantation, we inherently possess these skills. Emerging leaders need direction, training, mentorship, and support. This paper hopes to help the reader with the first step, that is, the direction to take when embarking upon a career in leadership in transplantation.

Volume: 20 Issue: 3 March 2022 - Supplement - 1

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