Liver transplantation (LT) is a demanding and highly specialized procedure requiring coordination among different specialists. Ensuring that future professionals acquire the necessary expertise is essential, yet a career in LT is often perceived by residents as inaccessible or unattractive. In Spain, LT training is not systematically integrated into residency programs. This study aimed to explore the training experiences, motivations and perceptions of medical residents from LT-related specialties.
MethodsA working group from the Spanish Society of Liver Transplantation (SETH) designed an online survey assessing demographics, LT exposure and attitudes toward LT, including perceptions of workload, burnout and motivation to pursue a future career in LT. The survey was sent through national scientific societies to residents in general and digestive surgery, gastroenterology, internal medicine and anesthesiology.
ResultsA total of 280 residents completed the survey (60.3% women). Most respondents (62.1%) trained at hospitals with an LT program, as LT training is significantly more common at these hospitals than at hospitals without LT programs (86.8% vs 41.5%; P < .001). Only 14.6% considered it an accessible career path. Although 38.2% expressed interest in pursuing a career in LT, 86.9% viewed it as difficult to achieve. The main disincentives were poor work–life balance and frequent night shifts.
ConclusionsLT training among Spanish residents remains inconsistent and largely unstructured. Despite recognizing its prestige and educational value, residents perceive LT as demanding and inaccessible. Establishing standardized LT training and offering targeted incentives may help attract future specialists to this critical field.
El trasplante hepático (TH) es un procedimiento exigente y altamente especializado que requiere la coordinación de distintos especialistas. Garantizar que los futuros profesionales adquieran la experiencia necesaria es fundamental; sin embargo, la carrera en TH suele percibirse por los residentes como inaccesible o poco atractiva. En España, la formación en TH no está integrada de forma sistemática en los programas de residencia. Este estudio tuvo como objetivo explorar las experiencias formativas, las motivaciones y las percepciones de los médicos residentes de las especialidades relacionadas con el TH.
MétodosUn grupo de trabajo de la Sociedad Española de Trasplante Hepático (SETH) diseñó una encuesta que evaluaba variables demográficas, formación en TH y actitudes hacia esta área, incluyendo percepciones sobre la carga de trabajo, el burnout y la motivación para seguir una carrera profesional en TH. La encuesta se difundió a través de sociedades científicas nacionales entre residentes de cirugía general y digestiva, aparato digestivo, medicina interna y anestesiología.
ResultadosUn total de 280 residentes completaron la encuesta, de los cuales el 60,3% eran mujeres. La mayoría de los encuestados (62,1%) se formaban en hospitales con programa de TH, siendo la formación en TH significativamente más frecuente en estos centros que en aquellos sin programa (86,8% vs. 41,5%; p < 0,001). Solo el 14,6% consideró el TH como una opción profesional accesible. Aunque el 38,2% manifestó interés en seguir una carrera en TH, el 86,9% lo percibió como difícil de alcanzar. Los principales factores disuasorios fueron la mala conciliación entre la vida laboral y personal y la frecuente nocturnidad.
ConclusionesLa formación en trasplante hepático entre los residentes españoles sigue siendo heterogénea y en gran medida no estructurada. A pesar de reconocer su prestigio y valor formativo, los residentes perciben el TH como una disciplina exigente e inaccesible. El establecimiento de una formación estandarizada en TH y la oferta de incentivos específicos podrían ayudar a atraer a futuros especialistas a este campo crítico.
Liver transplantation (LT) is a complex procedure that requires skilled input from professionals across different fields: surgery, hepatology, anesthesiology, intensive care, etc.
From the outset, LT as a procedure has been limited to a small number of hospitals and specialists, and many professionals have considered it a field of considerable interest. Over time, the procedure has become standardized, although it continues to be demanding for those involved. Indeed, a recent study carried out by the Spanish Society for Liver Transplantation (SETH) found high levels of burnout among Spanish professionals working in the field.1 Also of concern was that 21% of the specialists surveyed did not see themselves being part of the LT team in 5 years’ time, while over 20% of medical residents did not foresee a future as an LT specialist. Other studies conducted in Europe and the USA have reported similar results.2–8 Likewise, research in the USA has shown that transplantation fellowship programs are among the least in demand.8,9
The aim of this study was to survey Spanish medical residents from different specialties to explore the training they receive in adult LT and to gather their opinions about working in this field.
MethodsMembers of the SETH scientific committee drew up a 31-item survey to be sent to medical residents from across the different specialties covered by the Society.
Study populationThe target population comprised medical residents in the areas of general and digestive surgery, gastroenterology and internal medicine, and anesthesiology, who were thus potential future specialists in the main clinical fields associated with adult LT.
Survey designThe survey was based on one previously designed for general surgery residents, which was adapted to include the other specialties.10 The 31 questions were grouped into 4 blocks, covering demographics, factors related to LT training during the residency program, and opinions about LT as a profession, including perception of burnout and interest in or motivation to pursue a future career in the field.
Dissemination of the surveyAn email introducing the study and containing a survey link was sent to representatives from the SETH, the Spanish Association of Surgeons (AEC), the Spanish Association for the Study of the Liver (AEEH), the Spanish Society of Gastroenterology (SEPD) and the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR). These societies forwarded it to 1697 medical residents (SETH 88, AEC 1123, AEEH 200, SEDAR 286). The invitation was also shared on the SEPD website and social media, and the email was re-sent 2 weeks later.
Statistical analysisCategorical variables were described as frequencies and percentages; continuous variables were reported as median and interquartile range (IQR). Between-group differences were tested with Wilcoxon rank-sum or chi-square tests. Significance was set at P < .05. All analyses were performed using IBM SPSS 25.0.
ResultsA total of 280 residents responded to the survey (overall response 16.6%). Most were from general and digestive surgery (52.5%), with a predominance of women (60.3%). Respondents represented all 5 residency years (Fig. 1). Out of the total number of email invitations sent, the most responsive area by specialty was anesthesiology (31.5%), while the least was general surgery (13.1%). Among the residents contacted through the AEEH (internal medicine and gastroenterology), a total of 43 (21.5%) responded.
Training
A total of 174 residents (62.1%) were working hospitals with LT programs, where compulsory training in LT was much more likely to form part of residency (Table 1).
Compulsory training in liver transplantation according to hospital type and specialty.
| Hospital with LT program | Hospital without LT program | P-value | |
|---|---|---|---|
| 174 (62.1%) | 106 (37.9%) | ||
| Surgery, n = 147 | 88/90 (97.8%) | 36/57 (66.2%) | <0.001 |
| Anesthesiology, n = 90 | 36/54 (66.7%) | 3/36 (8.3%) | <0.001 |
| Gastroenterology, n = 31 | 18/19 (94.7%) | 5/12 (38.5%) | 0.002 |
| Internal medicine, n = 12 | 9/11 (81.8%) | 0/1 | 0.25 |
| Total sample, n = 280 | 151/174 (86.8%) | 44/106 (41.5%) | <0.001 |
LT: Liver transplantation.
Regarding whether the presence of an LT program had influenced their choice of hospital, 148 residents (52.9%) stated that it had been an incentive. However, 35 respondents (12.5%) would have preferred a hospital without an LT program. There were no differences between men and women in this regard (10.2% vs 13.8%; P = .66). Negative perceptions were most frequent among general and digestive surgery residents (Fig. 2).
Among the 106 respondents from hospitals without LT programs, 27 (25.5%) stated that their hospital or teaching unit did not provide training in LT, a phenomenon that most commonly affected residents in the areas of general and digestive surgery (94.6%) and gastroenterology (58.3%), as opposed to anesthesiology (23.5%) (P < .001).
Overall, 86.5% of respondents had done or had considered doing an LT rotation. Those uninterested were mainly anesthesiology residents (24/90; 26.7%) and least often surgical residents (8/147; 5.4%) (P < .001). Median LT training during residency was 2 months (IQR 1–8), ranging from 6 months among surgical residents (IQR 2–12) to 0 months in anesthesiology (IQR 0–2) (P < .001); gastroenterology and internal medicine residents reported 2 months (IQR 1–4) and 2 months (IQR 1.3–5.5). Residents from hospitals with an LT program spent longer time on LT training than their peers whose hospital did not offer such a program (5 [2–12] months vs 2 [0–2] months; P < .001). The greatest difference of this kind was observed among surgical residents (11 [6–14.3] vs 2 [1.5–2] months; P < .001).
Half of respondents (49.6%) had considered applying for European Union of Medical Specialists (UEMS) accreditation, particularly those in hospitals with LT programs.
Regarding the perceived value of experience in LT for their overall training as specialists (rated on a 10-point scale from 1 [none] to 10 [essential]), the median rating was 8 (IQR 7–9) vs 7 (IQR 6–8) for residents in hospitals with or without an LT program, respectively. Ratings did not differ across specialties.
Opinion about LT as a professionOnly 55 (19.6%) residents considered LT a well remunerated profession, 126 (45.0%) believed it was not, and 99 (35.4%) were unsure. Furthermore, only 41 (14.6%) residents thought that LT as a subspecialty would be accessible to them if they wished to pursue such a career. None of the gastroenterology residents considered LT an accessible profession, versus 19 (12.9%) surgical residents and 17 (18.9%) anesthesiology residents (P = .03). When asked to rate accessibility on a scale from 1 to 10, the overall median rating was 5 (IQR 3–6). The rating was slightly higher among residents whose hospital had an LT program (5 [IQR 3.8–7] vs 4 [IQR 3–6]; P < .001). By specialty, the lowest rating was from surgical residents (median 4 [IQR 3–6]), followed in ascending order by gastroenterology (median 5 [IQR 4–6]), anesthesiology (median 5 [IQR 3–7]) and internal medicine (median 6.5 [IQR 5–7]) (P = .03).
Table 2 presents residents’ perceptions of job satisfaction in LT, level of commitment required compared with other specialties, perceived degree of burnout associated with the field, and level of professional prestige.
Comparison of liver transplantation with other specialist areas in terms of perceived job satisfaction, required commitment, burnout and prestige.
| Surgery | Anesthesia | Gastroenterology | Internal medicine | All | |
|---|---|---|---|---|---|
| 147 (52.5%) | 90 (32.1%) | 31 (11.1%) | 12 (4.3%) | 280 | |
| Job satisfaction | |||||
| More than other areas | 63 (42.8%) | 34 (37.7%) | 14 (45.2%) | 4 (33.3%) | 115 (41.1%) |
| Same as other areas | 38 (25.9%) | 41 (45.6%) | 12 (38.7%) | 7(58.4%) | 98 (35.0%) |
| Less than other areas | 46 (31.3%) | 15 (16.7%) | 5 (16.1%) | 1 (8.3%) | 67 (23.9%) |
| P-valuea | 0.003 | 0.17 | -- | 0.01 | |
| Required commitment and demands | |||||
| More than other areas, but worth it | 50 (34.0%) | 46 (51.1%) | 19 (61.3%) | 8 (66.6%) | 123 (43.9%) |
| Same as other areas | 7 (4.8%) | 12 (13.3%) | 8 (25.8%) | 2 (16.7%) | 29 (10.4%) |
| Excessive | 90 (61.2%) | 32 (35.6%) | 4 (12.9%) | 2 (16.7%) | 128 (45.7%) |
| P-valuea | <0.001 | <0.001 | 0.003 | ||
| Burnout | |||||
| More than other areas | 114 (77.6%) | 49 (54.4%) | 14 (45.2%) | 4 (33.3% | 181 (64.6%) |
| Same as other areas | 31 (21.1%) | 36 (40.0%) | 16 (51.6%) | 8 (66.7%) | 91 (32.5%) |
| Less than other areas | 2 (1.3%) | 5 (5.6%) | 1 (3.2%) | 0 | 8 (2.9%) |
| P-valuea | <0.0001 | <0.001 | 0.002 | ||
| Prestige | |||||
| More than other areas | 90 (61.2%) | 42 (46.7%) | 13 (41.9%) | 8 (66.7%) | 153 (54.6%) |
| Same as other areas | 44 (29.9%) | 43 (47.8%) | 14 (45.2%) | 3 (33.3%) | 105 (37.5%) |
| Less than other areas | 7 (4.8%) | 2 (2.2%) | 3 (9.7%) | 0 | 12 (4.3%) |
| Other responses/No response | 6 (4.1%) | 3 (3.3%) | 1 (3.2%) | 0 | 10 (3.6%) |
| P-valuea | 0.05 | 0.14 | 1.0 | ||
When asked whether they would like to pursue a career in hepatology or hepatopancreatic-biliary surgery, 127 (45.4%) of those surveyed said ‘yes’, 53 (18.9%) responded ‘no’, and the remaining 100 (37.7%) were unsure. No differences were observed between specialties. Regarding their interest in LT as a future profession, 107 residents (38.2%) said they would like to follow this career path, although the majority (93/107; 86.9%) considered it difficult to achieve. A total of 53 residents (18.9%) said they would prefer not to work in an LT unit, while 23 (8.2%) had no desire at all to do so; this lack of interest in LT was most common among general and digestive surgery residents.
Residents were also asked to indicate the most appealing aspect of a future career in the field of LT. Overall, the most commonly chosen out of the 5 response options (n = 92, 32.9%) was the opportunity for professional development. Fig. 3 shows the frequency of options chosen by specialty.
Finally, residents identified work–family balance as the main deterrent to working in LT units (median = 100), with no differences observed between genders. Poor financial rewards and a long learning curve were least relevant (median = 40). Some variation was observed across specialties (P = .003) (Table 3).
Factors considered disincentives to pursue a career in liver transplantation, by specialty and gender.
| Surgery | Anesthesia | Gastroenterology | Internal medicine | Surgery | P-value (by specialty) | |
|---|---|---|---|---|---|---|
| 147 (52.5%) | 90 (32.1%) | 31 (11.1%) | 12 (4.3%) | 147 (52.5%) | ||
| Frequent night shifts | ||||||
| Total sample | 80 (60−100) | 100 (80−100) | 80 (40−80) | 80 (80−100) | 80 (60−100) | 0.001 |
| Female | 80 (60−100) | 100 (80−100) | 60 (40−80) | 90 (15−100) | 80 (60−100) | 0.001 |
| Male | 80 (45−100) | 90 (65−100) | 80 (50−80) | 60 (10−95) | 80 (60−100) | 0.25 |
| P-value (by gender) | 0.32 | 0.35 | 0.22 | 0.57 | 0.62 | |
| Excessive working hours | ||||||
| Total sample | 60 (20−80) | 60 (40−80) | 80 (40−80) | 60 (45−95) | 60 (20−80) | 0.05 |
| Female | 60 (20−80) | 60 (20−80) | 80 (60−80) | 80 (45−100) | 60 (20−80) | 0.03 |
| Male | 60 (20−80) | 60 (40−80) | 80 (25−95) | 60 (30−60) | 60 (40−80) | 0.20 |
| P-value (by gender) | 0.58 | 0.71 | 0.87 | 0.21 | 0.68 | |
| Difficult to combine with family life | ||||||
| Total sample | 100 (80−100) | 80 (60−100) | 80 (60−80) | 70 (20−100) | 100 (70−100) | <0.001 |
| Female | 100 (80−100) | 80 (60−100) | 80 (60−100) | 80 (30−100) | 100 (80−100) | 0.009 |
| Male | 100 (80−100) | 80 (60−100) | 80 (60−95) | 30 (20−85) | 80 (80−100) | 0.03 |
| P-value (by gender) | 0.49 | 0.59 | 0.63 | 0.37 | 0.27 | |
| Long learning curve | ||||||
| Total sample | 40 (20−80) | 40 (20−65) | 40 (0−80) | 60 (45−95) | 40 (20−80) | 0.12 |
| Female | 60 (20−80) | 40 (20−80) | 20 (0−80) | 40 (20−75) | 40 (20−80) | 0.11 |
| Male | 40 (0−80) | 40 (20−75) | 70 (15−80) | 90 (60−100) | 40 (20−80) | 0.04 |
| P-value (by gender) | 0.14 | 0.78 | 0.28 | 0.07 | 0.61 | |
| Difficult to progress within the team | ||||||
| Total sample | 60 (20−80) | 40 (20−80) | 80 (20−100) | 30 (5−75) | 60 (20−80) | 0.04 |
| Female | 60 (35−80) | 40 (20−80) | 40 (20−100) | 40 (20−75) | 40 (20−80) | 0.04 |
| Male | 60 (20−80) | 40 (20−80) | 80 (65−95) | 10 (0−65) | 60 (20−80) | 0.18 |
| P-value (by gender) | 0.65 | 0.48 | 0.28 | 0.28 | 0.47 | |
| Poor financial rewards | ||||||
| Total sample | 40 (20−80) | 50 (0−80) | 60 (20−80) | 40 (0−75) | 40 (20−80) | 0.67 |
| Female | 40 (20−80) | 40 (20−80) | 60 (35−80) | 30 (0−75) | 40 (20−80) | 0.55 |
| Male | 40 (20−80) | 40 (20−75) | 70 (5−80) | 40 (10−70) | 40 (0−80) | 0.60 |
| P-value (by gender) | 0.69 | 0.17 | 0.98 | 0.93 | 0.59 | |
Rated on a 100-point scale.
Median (IQR).
In this survey of medical residents from 4 LT-related specialties, only 38.2% said they would consider a future career in this field, while 45.4% expressed an interest in hepatology or hepatic surgery in general. The primary disincentives to working in an LT unit were the difficulty of achieving work–life balance as well as frequent night shifts, followed by excessive working hours, a long learning curve, limited career progression, and poor financial rewards.
To our knowledge, this is the first survey to have simultaneously explored the training, motivations and opinions of medical residents in the 4 main specialties associated with LT. Previous reports have been limited to surgical residents or physicians.3,9 In a survey conducted in Spain among heads of surgery and residents on LT teams, 42% of chief surgeons advocated for a fellowship training system, and 87.5% considered that generational handover was ensured.10 However, our findings suggest otherwise. Similarly,7 a survey of 180 gastroenterology fellows in the USA found that 86% were undecided or not planning to train in hepatology, and 21% had no interest in a transplantation hepatology fellowship. Just over half (52%) said that financial compensation equivalent to their gastroenterology colleagues would influence their decision. While our results are similar, our inclusion of 4 specialties and all residency years provides a broader perspective. These results are of particular concern given research highlighting the shortage of specialists in general hepatology, and even more so in LT.8,11
LT requires highly specialized multidisciplinary expertise. While other countries have established LT fellowship, access in Spain and many European countries depends on current demands within LT teams and the personal motivation of residents.
The low response rate in our survey is typical for a study of this kind. To maximize reach, invitations were distributed through scientific societies and social media. Response rates varied markedly by specialty: anesthesiology residents responded at nearly twice the rate of others. This may reflect not only outreach limitations but also differing levels of interest in LT across specialties. We believe that the sample of 280 responses is sufficiently representative, especially when compared with the number of participants in previous studies using similar methodology.7
In terms of training, 12.5% of residents preferred hospitals without LT programs and had not completed or did not wish to complete a rotation in transplantation, which is in line with previous reports.7 Another 34.6% were indifferent to whether their training hospital had an LT program. Notably, training in LT was not mandatory in 30.0% of hospitals, and 23.7% of hospitals without LT programs did not facilitate rotations in LT. This contrasts sharply with the residency program of those specialties that do include a period of training in transplantation hepatology.12
Familiarity with LT is essential for stimulating interest; thus, structured mentorship and career planning are vital for academic development in specialized fields.13 Training committees should promote LT exposure and ensure that off-hour LT activities are adequately compensated, similar to on-call shifts. Only 19.6% of residents considered LT work fairly remunerated, revealing notable disparities across hospitals and specialties.
Previous studies have concluded that remuneration is not the primary factor driving a lack of motivation or burnout in the field of LT, and the results of the present survey support this.1,14 Rather, the main obstacle to a career in LT appears to be the difficulty of achieving a work–life balance.1,14,15 Studies of LT professionals suggest that this is particularly a challenge for women, especially within the surgical field, a finding that has been corroborated by the systematic review conducted by Hoff et al.15 Interestingly, our survey revealed no significant gender or specialty differences regarding work–life balance.
Some studies have cited poor financial rewards as a major deterrent to pursuing transplantation hepatology,8,11 which suggests that shorter training programs and greater financial compensation may be key factors when it comes to promoting interest in this subspecialty. Differences in remuneration among specialties likely influence individual motivation when choosing career paths.
Most survey participants agreed that LT offers prestige comparable to other subspecialties, but the perceived burnout is also higher. Despite viewing LT as providing good professional development opportunities, only one-third expressed genuine interest in an LT career. The loss of specialists, especially surgeons, to other clinical areas will only be resolved by boosting training and offering incentives that are adapted to new generations of clinicians.4,6,7
In Spain, there are currently 26LT teams, although the number of specialists varies across hospitals. The aforementioned survey published in 2019 estimated that, by 2029, almost half of the current workforce in the field will have left.10 Given that training a transplant surgeon takes 10–15 years, this projection is troubling.3
Ensuring that current specialists are able to develop the skills they need to meet future demand is therefore essential. However, the present survey suggests that a career in LT is not seen by residents as particularly accessible or attractive.
A key factor to consider here is that LT teams are present in only a small number of hospitals nationwide, whereas opportunities to work in other less demanding specialist areas are more available. An insufficient number of trained transplantation specialists could lead to future capacity shortages—a concern shared across surgery and transplantation hepatology.4,8
The main limitation of this study was the challenge of reaching all medical residents nationwide, as recruitment relied on scientific societies and social media. Although the response rate was low, it was comparable to other clinical surveys (3%–34%).3,7 The low response rate likely reflected limited familiarity with LT (especially in hospitals without LT programs) or low interest in the field. It is likely that participating residents had either greater pre-existing interest in LT or higher levels of academic engagement, which may limit the representativeness of the sample and the generalizability of the findings to the overall resident population. Furthermore, the unequal distribution of responses across specialties, together with the high proportion of participants from hospitals with established transplant programs, may have influenced intergroup comparisons and led to an overestimation of actual exposure to LT during residency. Additionally, the data are based exclusively on self-reported information collected through a questionnaire that, although adapted from previous studies, is not reported to have been formally validated for all specialties included. This may introduce recall and social desirability biases, particularly in variables related to perceived prestige, burnout and career attractiveness. Moreover, some of the analyzed subgroups are characterized by small sample sizes, limiting statistical power and warranting cautious interpretation of the multiple comparisons performed. Differences in residency structures, healthcare systems and financial incentives among countries limit comparison. Nevertheless, we believe that the results likely reflect the situation elsewhere to a reasonable extent. Given the widespread concern among international scientific societies to establish general guidelines for LT fellowship programs, the results of this survey shed light on the motivations and needs of a current generation of medical residents and likewise provide insight to design training initiatives. Addressing the identified issues will be complex and likely require a multidimensional approach. It may be suggested that training program directors across the involved specialties promote mandatory rotations in LT and develop curricular incentives with recognized value in career progression. Furthermore, efforts to standardize working conditions across different healthcare systems—including workload, financial compensation and rest periods—should be considered, despite representing a significant challenge.
ConclusionsIn summary, this survey reveals the absence of structured training in liver transplantation for residents in Spain. The primary strength of the study is that we included residents from across the main clinical specialties involved in LT. The study highlights training and motivational gaps that health authorities could address to make this career path more attractive.
Ethical considerationsThis study did not involve research in patients or the use of clinical data; therefore, approval by an ethics committee was not required.
Informed consentNot applicable.
Declaration of Generative AI and AI-assisted technologies in the writing processThe authors declare that no artificial intelligence tools were used in the writing, analysis, or interpretation of the data in this manuscript.
FundingThis research has not received any specific grants from public sector agencies, commercial entities, or non-profit organizations.
IC-V: Travel grant from Chiesi and lecture fees from Chiesi and Astellas.
The authors gratefully acknowledge SETH, AEC, AEEH, SEPD and SEDAR for their support in the development of this study and the dissemination of this survey. We also thank Paloma Bellés (AOPC) as technical secretariat and Michael Maudsley for language edition.
