I’ve been able to sit in transplant review board (BCM), or selection (Cedars), several times at two academic institutions over the past year. This session occurs weekly in a conference room setting. For approximately one hour, various providers come together to discuss the ongoing management of live and mechanical transplant candidates and recipients.
Generally, a case presentation will play out as follows:
- An attending physician (usually the managing cardiologist) or a fellow will briefly present the patient’s clinical history including transplant status, followed by an update on the patient’s current clinical situation with emphasis on transplant-specific details (e.g. drug regiment, kidney function, cardiac enzymes, etc.).
- A semi-moderated discussion tailored to the patient’s transplant status ensues: a) If waiting on a donor, board participants will discuss the patient’s progress and decide if it is appropriate to submit a petition for his or her status to be elevated in priority and/or to implant a mechanical circulatory support (MCS) device, like a left ventricular assist device (LVAD) or the total artificial heart (TAH; photo is from the first implant at BCM in five years, performed last summer in 2016) (note: usually such a device functions as a bridge to transplant by providing the patient with additional functional support to ensure he or she is healthy enough to be a recipient), or b) If the patient already received a device or donor heart, what complicated problems have manifested post-op?
As a learner, it is important to recognize a few things and not get bogged down by preconceived notions of transplant review board.
- Each department represented at the meeting is distinct yet of equal importance in any patient’s care. For instance, heart transplants are expensive, costing nearly $1 million for the entirety of care (2011 estimate from UNOS). Financial representatives attend review board to ensure that the patient’s insurance plan adequately covers the associated costs. Additionally, legal counsel is often necessary for cases of patient non-compliance, i.e. with immunosuppressive medications.
- The conference table is typically reserved for attending physicians and fellows. Don’t make the mistakes I have and sit there without asking first. 😇 No one will say anything to you, but you will get some funny looks if you tell them that you are only a medical student.
- Some folks will undoubtedly be more outspoken than others. Take note of how physicians interact with their colleagues. Which characteristics are both effective in articulating your opinions and received well by others? How is one to be both assertive and respectful in this type of meeting? How do I tailor my talking points in such a way that everyone in the room (cardiologists, surgeons, nurse practitioners, transplant coordinators, palliative care, etc.) can follow along?
These sessions first really shook me: these people, albeit with immense knowledge and experience, have so much decision-making power over the lives of other very sick people who are in huge need of something they may never be able to obtain! I may find myself in such a unique position in the future, and observing these meetings has prompted me to more fully realize the privilege of responsibility we assume as healthcare providers. Balancing clinical acuity–which is often difficult in transplant scenarios, when donor organs are limited–and compassion is a skill I look forward to developing in medical school and throughout the rest of my career.