2019 ACS Traveling Fellow to Australia and New Zealand reports on experience

I was honored to be selected as the 2019 American College of Surgeons (ACS) Traveling Fellow to Australia and New Zealand (ANZ). The opportunity to collaborate with and learn from colleagues across the globe affords enhanced perspective and fuels shared vision and passion for the care of surgical patients, and I believe is at the heart of the traveling fellowship. Representing the ACS was the honor and experience of a lifetime. I hope in the paragraphs that follow you, too, will be inspired by commonalities we share with our global partners and the endless possibilities for driving our field forward as we continue to prioritize forging these relationships.

Sydney

Approximately 48 hours after leaving Birmingham, AL, and crossing the international dateline, I arrived in Sydney, Australia, as the 2019 ACS Traveling Fellow to ANZ. I had planned a four-hour journey to climb the Sydney Harbor Bridge to acclimate to Sydney time, and the summit afforded me a 360-degree view of city, including the famous Sydney Opera House and Watson’s Bay. Afterward, I felt prepared for my busy few days at Westmead Hospital.

Over the next several days, I was immersed in all things transplant at Westmead, home to the editorial offices of Transplantation, the preeminent international transplant journal. I had planned to focus my visit to Westmead entirely on research and publication processes. My host, Henry Pleass, MD, FRACS, transplant surgeon and consultant, weaved opportunities to observe and discuss the clinical programs within the broader framework of academics. The collective experiences reminded me of the importance of being both a surgeon and scientist, as it is the rare combination of the two that drives the field forward, enhances the lives of our patients, and educates the next generation of transplant surgeons.

The days began with presentations from the registrars (or residents) on difficult cases from ward rounds. One case in particular, presented by the transplant surgery fellow Jinna Yao, MD, clinical associate lecturer, highlighted a recent hyperacute rejection after a blood group incompatible (ABOi) living donor kidney transplant. The ABOi living donor kidney transplant program follows the same desensitization regimen/paradigm as my program at the University of Alabama at Birmingham (UAB), which includes the use of total plasma exchange (TPE) and low-dose intravenous immunoglobulin (IVIg) to remove anti-ABO antibodies before crossing the blood group barrier for transplant. Multiple studies, including those conducted at Westmead, have demonstrated success with this technique over the years.

This particular case did not go as planned, and the kidney was immediately rejected. Listening to the details of the case, observing the pain on the registrar’s face and the frustration of Professor Pleass, I felt a common bond with my colleagues that traversed oceans and nationalities. We have much more in common than we realize. It was gratifying to be able to share a similar case that occurred at UAB. I was able to alert them to the need to check ABO antibody levels in the IVIg before administering the medication, as preparation can vary widely. In other words, similar to my experience at UAB, it is likely that the very antibodies that were the target of removal by TPE were inadvertently returned to the patient during the IVIg infusion. Not only did I have a shared experience, but that experience forged a bond and collaboration that will endure for years to come.

Prof. Richard Haney, MBBS, FACS, FRACS, invited me to lecture at surgical grand rounds, during which I discussed Finding Your Passion: A Career Road Map. I described both my successes and failures with ease and without concern for judgment. Faculty joined the discussion and shared their personal career road maps. I found this session particularly rewarding, as it actively engaged trainers (consultants) and trainees (registrars) in a productive and meaningful way.

After grand rounds, we joined the transplant research conference, where I reunited with friends from The Transplantation Society and the editorial board of Transplantation, including Prof. Philip O’Connell, MBBS, BSc[med], PhD, FRACP, past-president, The Transplantation Society, and Prof. Allison Tong, PhD, co-leader, Centre for Kidney Research. We spent several hours discussing ongoing research projects at both UAB and Westmead and realized that in many ways, our patient populations are similar—rural/remote and often poor—and that we are attempting to overcome these disparities in similar ways by incorporating patient navigators into the care of our patients. We recently published initial results from the UAB Living Donor Navigator Program in Transplantation. Professors O’Connell and Tong read the article with interest, as they recently developed and implemented the Patient NAvigator program for Early Chronic Kidney Disease (PAVE-CKD). Discussing findings and implementation hurdles was invaluable. I left with actionable items to examine in UAB’s navigator program that may lead to improved adaptation and maintenance.

My days ended with extraordinary team dinners from Malaysian cuisine in the Harbor to tremendous seafood at Watson’s Bay.

Auckland

I said goodbye to my colleagues and friends at Westmead Hospital and headed for Auckland, New Zealand. There, my host Prof. Stephen Munn, MBChB, had arranged a spectacular dinner at Mudbrick Vineyards on Waiheke Island (the “Island of Wine”). The wine was extraordinary, but the view looking across the harbor at mainland New Zealand was even better.

The next day, I was eager to learn from colleagues about their national policies on living donor compensation, as this is an area of active clinical and research practice for me. The topic is hotly debated in the U.S., with no current resolution. Members of the transplant community who favor providing compensation to living donors feel that it is important that these altruistic individuals be made whole and not suffer a financial loss as a result of the donation, while those individuals opposed cite concerns of coercion and promotion of organ trafficking. However, it is possible to satisfy both parties, as our colleagues in New Zealand have demonstrated. Professor Munn and colleagues from Christchurch, including Dilip Naik, MBChB, FRACS, were instrumental in supporting the passage of the New Zealand Compensation for Live Organ Donors Act 2016, which was intended to remove a financial deterrent to the donation of organs by live donors. In brief, the act gives eligible donors an entitlement to compensation for loss of earnings from employment while they recuperate from surgery and in limited circumstances for loss of income related to the donor evaluation process. Since implementation, the number of living donors has steadily increased without any observed increase in exploitation through organ trafficking. The data are impressive. Armed with data and real-world observation, I felt encouraged and more confident about effecting similar change back home.

Bangkok

We finished in Auckland just in time to make our way to Bangkok, Thailand, for the 88th Annual Scientific Congress of the Royal Australasian College of Surgeons (RACS). I was excited to be reunited with my colleagues from Sydney and New Zealand during the transplant section meetings before the start of the conference. I was the guest of Dr. Naik and had been asked to give several talks, ranging from the U.S. allocation system, to simultaneous liver kidney transplantation, to incompatible kidney transplantation.

The section meeting was a success. I was told it was the best turnout in years. I enjoyed the series of lectures and connected with colleagues from Europe, Profs. Peter Friend, MD, and Anthony Warrens, MD, president, British Society of Transplantation. We discussed normothermic perfusion of liver allografts both ex-vivo and regional perfusion. Their results demonstrated increased use of livers from donation after cardiac death (DCD) donors and little to no problems with ischemic cholangiopathy, the most dreaded long-term complication of DCD liver transplants. I thought about all the lives we could save if we expanded our own experience with ex-vivo normothermic perfusion to regional perfusion.

I also was invited to participate in the Developing a Career and Skills in Academic Surgery (DCAS) course, which Dr. Hanney led. It afforded me additional opportunities to interact with trainees and possibly pique their interest in becoming a transplant surgeon-scientist. We discussed achieving academic balance and developing a career as a surgeon-scientist. It was an honor to be able to interact with the trainees, and I felt like perhaps I was starting to pay forward all the successes I have achieved because of excellent mentorship.

As the ACS Traveling Fellow to ANZ, the meeting was enhanced with the pomp and circumstance of the opening ceremony. It was an honor to present the ACS lecture and be introduced by John Batten, MBBS(Hon), FRACS, FAOrthA, RACS president, and to attend the celebration lunch with Julian Smith, MB, BS, MS, MSurgEd, FACS, FRACS, FFSTRCSEd, FCSANZ, FAICD, Governor of the ANZ Chapter, and Ronald V. Maier, MD, FACS, FRCSEd(Hon), FCSHK(Hon), FCCS(Hon), then-ACS President, at the meeting of the ACS ANZ Chapter. The privilege of meeting giants in surgery and sharing the podium with international experts was humbling and exhilarating.

The fellowship was an opportunity of a lifetime. It was an extraordinary journey from which grew countless friendships and collaborations. It has been my great privilege to be the ACS ANZ Traveling Fellow in 2019.