Landscape of Current Transplant Infectious Disease Training Programs

ABSTRACT

Background

Transplant infectious disease (TID) training is not accredited by the Accreditation Council for Graduate Medical Education (ACGME) and is not standardized. Prior surveys of the training landscape in TID have focused on fellow responses; we sought description of programs from program directors and coordinators.

Methods

Along with the American Society of Transplantation (AST) Infectious Disease Community of Practice (IDCOP), we administered a survey to adult and pediatric ID training programs focusing on the structure, funding, curriculum, and outcomes of ID fellows participating in TID fellowships and tracks. This manuscript is a work product of the American Society of Transplantation's Education Committee.

Results

We had 42 respondents representing 15 adult TID fellowships, 12 adult TID tracks, 4 pediatric TID fellowships, and 6 pediatric TID tracks. Adult TID fellowships required slightly more inpatient weeks than adult TID tracks: 26 versus 24 (p = 0.03). A majority of adult TID fellowships 10/14 (71%) rely on multiple sources of funding for their programs. A total of 67% of adult and 75% of pediatric TID fellowships have didactic curriculum, distinct from their general fellowship, and 53% of adult TID fellowships and no pediatric TID fellowships have distinct core competencies to evaluate TID fellows. Most TID fellows are pursuing TID‐focused clinical careers.

Conclusions

Substantial heterogeneity exists among TID fellowships, and between fellowships and tracks. Future directions include updating prior guidance for adult and pediatric TID tracks and fellowships on curriculum, core competencies, and baseline requirements to ensure adequate competency in the care of these vulnerable patients.

Abbreviations

ACGME

Accreditation Council for Graduate Medical Education

AST IDCOP

American Society of Transplantation Infectious Disease Community of Practice

FQHC

Federally Qualified Health Centers

HSCT

hematopoietic stem cell transplantation

LTAC

long‐term acute care

PID

pediatric infectious disease

PTID

pediatric transplant infectious disease

SLK

simultaneous liver‐kidney transplant

SOT

solid organ transplantation

SPK

simultaneous pancreas‐kidney transplant

TID

transplant infectious disease

USA/US

United States of America

VA

Veterans Administration

1. Introduction

Transplant infectious disease (TID) is a subspecialty within infectious disease (ID) that focuses on the care of immunocompromised patients after hematopoietic stem cell transplantation (HSCT) or solid organ transplantation (SOT). TID training is not accredited by the Accreditation Council for Graduate Medical Education (ACGME) and is not standardized.

In 2010, the American Society of Transplantation Infectious Disease Community of Practice (AST IDCOP) published curricular recommendations for adult TID training programs, outlining core competencies relating to the care of patients after SOT and HSCT [1]. To become competent, AST IDCOP recommends at least 24 weeks of supervised clinical service and mentored research time that leads to at least an abstract, but ideally a submitted manuscript. In their 2015 recommendations for pediatric TID training, Pediatric Infectious Diseases Society (PIDS) and International Pediatric Transplant Association highlighted unique competencies: understanding the role of growth, development, and immunologic maturation; expertise in the increased risk of primary infections in the post‐transplant period; and the ability to manage the complexities of immunizations before and after transplantation. These recommendations were supported by a recent editorial informed by an online discussion among TID fellows, which also called for incorporating TID‐specific educational experiences such as simulated donor calls [2].

Despite these recommendations being published more than 10 years ago, adult and pediatric TID programs are not standardized, and the field has continued to evolve with more programs offering formal TID training every year. Previous surveys of ID fellows identified strong interest in TID training and future careers in TID, but perceived gaps in TID curriculum and opportunities for new educational resources [3, 4].

In this study, we describe the structure, funding, curriculum, and outcomes of adult and pediatric TID programs as informed by fellowship program directors and coordinators. We describe current gaps in available training relative to previously outlined recommendations [1, 5]. This manuscript is a work product of the American Society of Transplantation's Education Committee.

2. Methods

We used survey methods to describe adult and pediatric TID training programs across the United States. Adult TID programs of interest were identified from review of all 151 ACGME accredited ID fellowship websites listed on IDSA website (https://www.idsociety.org/education–training/training‐and‐curriculum/id‐fellowship‐training‐program‐directory/), conducted in September 2022, and then updated in December 2023. Programs were invited to participate if they advertised any TID‐specific training, either a track or a fellowship. We invited all pediatric infectious disease (PID) fellowship programs active for the 2024 match cycle. Surveys were distributed to adult ID program directors (PDs) and coordinators via listed email on program websites and through the AST IDCOP forum, and to PID PDs via PIDS listserv. We targeted a second round of invitations to PID fellowships known to have TID training from the PIDS website (https://pids.org/education‐training/resources‐for‐fellows/).

We defined a TID fellowship as a separate year(s) after an adult or pediatric general ID fellowship offered at the responding institution and a TID track as a program within the ACGME‐accredited adult or pediatric ID fellowship. We defined other TID training opportunities as any exposure to TID, a designation only applicable to the pediatric survey, as adult programs were invited to the survey if they advertised a TID fellowship or track. We define “TID fellows” as those in a TID fellowship. We consulted with the University of Wisconsin Survey Center for design and distribution of the survey (Qualtrics (2025). Qualtrics Experience Management. https://www.qualtrics.com), with unique surveys for adult and pediatric programs (full instruments available in Supporting Information S2 and S3). We queried the current and past status of TID training, the structure of the clinical and research experiences by fellows, outcomes of fellows after training, and programmatic details such as funding and leadership. All respondents were offered a token of appreciation ($50) for completing the survey. Surveys remained open for less than 4 weeks to maximize response rate, and multiple reminders were sent.

When respondents answered a question with an estimated range rather than a single value, we used the lower value (e.g., TID inpatient weeks, consults/year). Non‐parametric data were compared using chi‐square and Kruskal–Wallis tests where appropriate. All statistical analyses were performed using R (Vienna, Austria, version 4.4.1). This work was IRB‐exempt and does not constitute human subject research.

3. Results

3.1. Identification of TID Training Programs

3.1.1. Recruitment, Inclusion, and Exclusion of Programs

We reviewed 148 ACGME adult ID Fellowship program websites that were active in the 2022 match cycle and identified 52 with a TID training program: adult TID track only (51.0%, 26/51), fellowship only (29.4%, 15/51), or both track and fellowship (19.6%, 10/51). Our survey response rate for adult TID training programs was 43.1% (22/51). After the addition of a Canadian program not initially recruited, we included 23 unique institutions that completed the survey. Of 23, 19 (82.6%) had active adult TID training programs representing 12 tracks and 15 fellowships; 4/23 (17.4%) did not have an active training program (Figure 1).

FIGURE 1.

Flow diagram of program recruitment, inclusion, and exclusion.

The response rate for the PID survey was 46.2% (18/39). After the addition of a Canadian program not initially recruited, we included 19 unique institutions. Nine out of 19 (47.4%) offered TID training, representing six tracks and four fellowships; 10/19 (52.6%) did not have an active training program (Figure 1).

3.2. TID Fellowship Clinical and Research Experiences

3.2.1. Clinical Experiences

3.2.1.1. Training Locations, Populations Served, and TID Fellow Time

Adult: All included adult TID fellowships (15 programs) are associated with academic medical centers. Training includes patients with SOT, HSCT, and hematologic malignancies. Solid tumor oncology is included in nine fellowships and eight include other populations—most commonly patients with left ventricular assist devices (LVAD) and patients receiving chimeric antigen T‐cell therapy (CAR‐T). Though most programs are at institutions performing heart, lung, liver, kidney, and pancreas transplantation, exposure to thoracic transplantation is not universal, with 3/15 (20%) and 2/15 (13%) programs being at institutions not performing lung or heart transplantation, respectively. Intestinal transplantation was even less common, being done only at 8/15 (53%) (Table 1).

TABLE 1.

Description of adult and pediatric TID fellowships and tracks.

	Adult TID fellowships: n = 15	Adult TID tracks: n = 12	Pediatric TID fellowships: n = 4	Pediatric TID tracks: n = 6
Median years that program has been offered (IQR)	8 (7)	8 (7.75)	7 (4.25)	6.5 (3)
TID training facilities: n (%)
Academic medical centers	15/15 (100%)	12/12 (100%)	4/4 (100%)	6/6 (100%)
Community medical centers	0/15	2/12 (17%)	0/4	0/6
LTAC/rehab hospitals	1/15 (7%)	1/12 (8%)	0/4	0/6
VA or government‐associated centers	2/15 (13%)	5/12 (42%)	Excluded	Excluded
FQHC	1/15 (7%)	1/11(9%) d	1/4 (25%)	1/6 (17%)
International center (e.g., partner institutions outside the United States)	0/15	1/12 (8%)	0/4	1/6 (17%)
Populations included in TID training: n (%)
SOT	15/15 (100%)	12/12 (100%)	4/4 (100%)	6/6 (100%)
Malignant hematology	15/15 (100%)	12/12 (100%)	4/4 (100%)	6/6 (100%)
HSCT	15/15 (100%)	12/12 (100%)	4/4 (100%)	6/6 (100%)
Solid tumor oncology	9/15 (60%)	7/12 (58%)	4/4 (100%)	6/6 (100%)
Inborn errors of metabolism	Excluded	Excluded	3/4 (75%)	5/6 (83%)
Primary immunodeficiency	Excluded	Excluded	3/4 (75%)	5/6 (83%)
Other	8/10 (80%) d	7/9 (78%) d	2/3 (50%) d	3/4 (75%) d
Organ transplantations performed at the institution: n (%)
Heart	13/15 (87%)	10/12 (83%)	4/4 (100%)	6/6 (100%)
Lung	12/15 (80%)	8/12 (67%)	2/4 (50%)	4/6 (67%)
Liver	14/15 (93%)	11/12 (92%)	4/4 (100%)	6/6 (100%)
Kidney	14/15 (93%)	11/12 (92%)	4/4 (100%)	6/6 (100%)
Pancreas	13/15 (87%)	11/12 (92%)	2/4 (50%)	2/6 (33%)
Intestinal	8/15 (53%)	5/12 (42%)	2/4 (50%)	3/6 (50%)
Heart‐lung	13/15 (87%)	8/12 (67%)	2/4 (50%)	4/6 (67%)
Multivisceral (e.g., SPK, SLK, heart‐kidney)	13/15 (87%)	11/12 (92%)	2/4 (50%)	3/6 (50%)
Minimum percent of TID fellow time required a : median % (IQR)	n = 12		n = 2 e
Inpatient consults	50% (6.25)		0% and 80% e
Outpatient clinic	10% (11.8)		0% and 20% e
Research/scholarship	22.5% (21.3)		90% and 25% e
Admin/committees b	5% (6.3)		10% and 5% e
Percent of TID fellow time with populations c : median % (IQR)	n = 15		n = 3 f
SOT	50% (5)		20%, 25%, 50% f
HSCT	40% (20)		35%, 25%, 40% f
Other	0% (17.5)		50%, 50%, 10% f

Abbreviations: FQHC, Federally Qualified Health Centers; HSCT, hematopoietic stem cell transplantation; LTAC, long‐term acute care; SLK, simultaneous liver‐kidney transplant; SOT, solid organ transplantation; SPK, simultaneous pancreas‐kidney transplant; VA: Veterans Administration.

^a Respondents were asked to consider TID fellows over the prior 3 years, asked to round to the nearest 10%, and the total percentage may not add to 100%.

^b Administration/committees defined to include antimicrobial stewardship, infection control, or other activities.

^c Respondents were asked to consider TID fellows over the prior 3 years, asked to round to the nearest 10%, and the total percentage should add to 100%.

^d Some respondents did not answer; denominators differ from listed n of subgroup. Other populations most commonly included patients with left ventricular assist devices and chimeric antigen T‐cell therapy.

^e Only two pediatric TID Fellowship programs answered, so the responses of each are listed rather than calculated a median percentage

^f Only three pediatric TID Fellowship programs answered, so the responses of each are listed rather than calculated a median percentage.

About 50% of time in fellowships is spent on inpatient consults, the median estimate for time spent in scholarship was 22.5%, in clinic, 10%, and in administrative or committee work, 5% (Figure 2). The median percentage of adult TID fellow time spent with SOT recipients was 50%, HSCT recipients 40%, and other patients 10% (Table 1). The median number of weeks required on inpatient TID service for adult TID fellows in a year was 26 (IQR 6; range 16–38). The median estimated number of inpatient TID consults per year for a TID fellow was 300 (IQR 245; range 70–800).

FIGURE 2.

Percent of adult TID fellow time by responding programs.

Pediatric: Pediatric TID fellowships (four programs) are all at academic medical centers, and their training includes patients with SOT, HSCT, hematologic malignancies, and solid tumor oncology. Unique to pediatric TID, 3/4 (75%) fellowships include inborn errors of metabolism and primary immunodeficiency training, and two programs evaluate patients with HSCT for non‐malignant indications, such as sickle cell disease and autoimmune disease on immunosuppression. All programs are at institutions performing heart, liver, and kidney transplantation, with only two performing lung, pancreas, or intestinal transplantation (Table 1).

Two of four pediatric TID fellowship programs described the minimum required time for TID fellows. The percentage of TID fellow time spent with SOT recipients ranged from 20% to 50%, HSCT recipients 25% to 40%, and other patients 10%–‐50% (Table 1). One pediatric TID fellowship indicated that they are primarily a research year, and clinical work is optional. This program was excluded from the analysis of inpatient consult volume. Only 2/3 programs responded with the number of required weeks of inpatient TID service, 18 and 20 weeks. Three programs estimated the number of inpatient TID consults per year for a TID fellow with a median of 200 (IQR 50; range 100–200).

3.2.1.2. Other Experiences

Adult: All 15 adult TID fellowship programs require TID‐specific clinics, and 13/14 (93%) also require pre‐transplant evaluations, 13/14 (93%) teaching experiences, and 14/15 (93%) scholarships such as posters, presentations, or manuscripts (Table 2). Adult TID fellows often rotate with hematopoietic stem cell transplant (47%), laboratory medicine (47%), medical transplant (nephrology or hepatology, 40%), and transplant surgery (27%). Less common electives were with hematology/oncology (7%) and a dedicated HIV service (13%). Other experiences noted by respondents included a local OPTN educational course, institutional tumor boards, and occasional electives with radiology and dermatology.

TABLE 2.

Other required experiences of TID fellowships and tracks.

	Adult TID fellowships: n = 15	Adult TID tracks: n = 12	Pediatric TID fellowships: n = 4	Pediatric TID tracks: n = 6
TID‐specific clinic	15/15 (100%)	12/12 (100%)	3/4 (75%)	5/6 (83%)
Donor screening	8/14 (57%)	—	2/4 (50%)	—
Pre‐transplant evaluation consults	13/14 (93%)	11/12 (92%)	3/4 (75%)	6/6 (100%)
Attending selection committee meetings	9/14 (64%)	6/12 (50%)	2/4 (50%)	4/6 (67%)
Antibiotic stewardship	8/14 (57%)	—	3/4 (75%)	—
Infection control	7/15 (47%)	—	1/4 (25%)	—
Creating or managing institutional guidelines	9/14 (64%)	—	2/4 (50%)	—
Administrative experience	11/15 (73%)	—	0/4	—
Teaching in lecture or didactic setting	13/14 (93%)	—	2/4 (50%)	—
Scholarship, such as posters, presentations, or manuscripts	14/15 (93%)	10/12 (83%)	3/4 (75%)	6/6 (100%)
Other experiences a	8/11 (73%)	—	3/4 (75%)	—

Note: Blank cells “—” indicate this was not asked regarding TID tracks.

^a Other experiences included a local OPTN educational course, internal tumor boards, occasional electives with radiology and dermatology, involvement with emergency investigational new drug applications, and clinical trials.

Pediatric: Of the four pediatric TID fellowships, 75% require TID‐specific clinics, 75% pre‐transplant evaluations, and 75% scholarship (Table 2). Two of four (50%) of pediatric TID programs expect rotations with HSCT, hematology/oncology, and laboratory medicine. One program indicated rotations with medical transplant and one program with a dedicated HIV service; none rotated with transplant surgery. Other experiences noted by respondents included involvement with emergency investigational new drug applications and clinical trials.

3.2.1.3. TID Fellowship Curriculum

Adult: Of the 15 adult TID fellowships, 12/15 (80%) referenced published recommendations when designing their curriculum [1]; 10/15 (67%) have a dedicated didactic curriculum distinct from the general ID fellowship. Core competencies distinct from general ID fellows are defined in 8/15 (53%) of programs, of which 4/8 (50%) were informed by local opinion, 3/8 (38%) partially adapted from recommendations, and 1/8 (13%) modeled on another TID fellowship program.

Pediatric: Of the four pediatric TID fellowships, 3/4 (75%) have a didactic curriculum for the TID fellowship distinct from the general ID fellowship curriculum. None has defined core competencies distinct from those used to evaluate general ID fellows. Half (2/4) followed published recommendations when designing their TID fellowship curriculum [5].

3.2.2. Research Experiences

Among adult and pediatric TID fellowships that reported on fellow scholarly efforts, the most common forms of scholarship were quality improvement, retrospective research, and translational research. All pediatric and half of the adult programs lacked basic science research efforts for their TID fellows. Half of the adult programs and three pediatric programs indicated that none of their graduating fellows over the prior three years sought funded research following their clinical training; the remaining adult programs estimated a few to some (< 25% to 50%) sought funding. One research‐intensive pediatric TID fellowship indicated most (> 50%) graduates sought funding (Figures S1 and S2).

3.3. TID Fellowship Recruitment, Faculty, and Funding

3.3.1. Fellowship Recruitment

Adult: Fourteen of the 15 responding adult TID fellowship programs describe their TID year as completed after a standard 2–3 year general ID fellowship, and one completes it concurrently. Most (80%) programs require a separate application outside of their general ID Fellowship. Internal applications are an important source of recruitment: 38% of programs recruit most or all TID fellows from their general ID fellowship, 29% indicated some to many (10%–50%) were internal; 38% recruited no TID fellows from their general ID fellowship. Of 12 respondents, 11 actively recruit fellows from other institutions. Of these 11, all indicated they rely on word of mouth and their program website, ten (91%) recruit via in‐person meetings (e.g., IDWeek, ATC), nine (82%) via online forums (e.g., IDSA, AST), and six (55%) use social media.

Pediatric: All four pediatric TID fellowship programs describe their TID year as completed after a standard 3‐year general PID fellowship, and all require a separate application from their general fellowship program applications. Only one program recruited their TID fellows entirely from their general ID fellowship; the three others had no TID fellows come from their own institution's general PID program. Of the two programs that recruit from other institutions, both use word of mouth and in‐person meetings (e.g., IDWeek, PIDS), and only one uses online forums or their program website. Neither uses social media.

3.3.2. Fellowship Faculty

Adult: Eleven of 15 (73%) adult TID fellowships have a dedicated TID fellowship PD, with the other four (27%) programs led by the general ID fellowship PD. Of the 11 programs with a dedicated TID PD, four (36%) are core ACGME faculty of the general ID fellowship, five (45%) are teaching faculty, and none act as associate PD for the general fellowship.

All 15 programs have faculty who focus clinical time on TID (> 50% clinical effort in TID), with a median of 6.5 faculty members (range 3–16). Very little TID training time is supervised by non‐TID faculty, with only one program indicating “some time” (10%–25%) supervised by non‐TID specialists. Three programs had at least 1 week of indirect or unsupervised consult service for the TID fellow.

Pediatric: Half of the four pediatric TID fellowships have a dedicated TID fellowship PD, and the others are led by the general PID fellowship PD. Of the two programs with a dedicated TID PD, one TID PD acts as an associated PD for the general PID fellowship.

All four programs have faculty who focus clinical time on TID (> 50% clinical effort in TID), with a median of 3.5 faculty members (range 1–4). When estimating how much pediatric TID fellow training is supervised by non‐TID focused clinical faculty, one program indicated a little (< 10%), one some (10%–25%), one quite a bit (25%–50%), and one a great deal (> 50%). None had TID fellows doing inpatient clinical work that is not directly supervised by clinical faculty.

3.3.3. Funding Mechanisms

After completing their general ID fellowships, TID fellows are hired as research or advanced fellows in 9/14 (64%) of adult fellowships and 3/4 (75%) of pediatric fellowships. In the remaining adult programs, they are hired as a clinical instructor and as a clinical postdoctoral fellow in the remaining pediatric program. The most common sources of funding for adult positions were from the Division of Infectious Disease 10/14 (71%), only 5/14 (36%) received funding from graduate medical education, but 10/14 (71%) programs identified combining funding from multiple sources. Among pediatrics, one had multiple funding mechanisms, the three others cited grants, Department of Pediatrics, and SOT center funding (Table S1).

3.4. TID Fellowship Outcomes

Adult and Pediatric: Most adult programs, 12/14 (85.7%), indicated most (> 50%) or all (> 100%) of their graduates seek clinically focused TID careers. Half of the pediatric programs, two out of four, have most (> 50%) of their graduates pursuing clinically focused TID careers. One pediatric program that described itself primarily as a research program indicated that most of its graduates were pursuing a career in research (Figure S3).

3.5. Comparison of TID Fellowships Versus Tracks Versus Other Experiences

Adult: Among the 19 adult programs with active TID training, 15 TID fellowships and 12 TID tracks responded to the survey (Figure 1). The adult TID fellowships and tracks have both been offered for a median of 8 years (IQR 7 years for fellowships; 7.75 years for tracks). The locations of TID training, the populations included were relatively similar between adult TID fellowships and tracks. Though the organ transplants performed at institutions were similar between tracks and fellowships, lung transplantation was numerically more common at fellowships than at tracks (12/15; 80% vs. 8/12; 67%) (p = 0.66) (Table 1). Eight of 12 (67%) adult TID tracks have a dedicated lead outside the general ID fellowship PD, who were most commonly core faculty (38%) or teaching faculty (38%); one track has their associate PD for the general ID fellowship as the TID track leader.

Adult TID fellowships require slightly more inpatient TID consult weeks than adult TID tracks, with a median of 26 (IQR 6; range 16–38) versus 24 weeks of TID (IQR 11.3; range 6–30) (p = 0.03); our survey did not ask respondents how weeks were distributed across training years in TID tracks while all TID fellowships were over 1 year. Like TID fellowships, TID tracks expected attendance in TID‐specific clinic (100%), pre‐transplantation consults (92%), and TID‐specific scholarship (83%). Only half of the tracks required fellows to attend selection committee meetings, while this was required in 64% of TID fellowships (Table 2).

Among the 19 programs with adult TID training, TID experiences for fellows not in a TID track or fellowship occurred most commonly on a separate, required TID service (79%). For others, TID experiences were integrated into the general ID consult service (11%) or offered as an elective experience (11%).

Pediatric: Along with the four pediatric TID fellowship programs, six pediatric TID tracks responded to the survey (Figure 1). The pediatric TID fellowships and tracks have been offered for a similar duration: median 7 years (IQR 4.25 years) for fellowships and median 6.5 years (IQR 3 years) for tracks. Two tracks had leads distinct from the general ID fellowship PD—one as associate PD and the other a teaching faculty. The locations of TID training, the populations included, and the organ transplantations performed at each institution were relatively similar between pediatric TID fellowships and tracks (Table 1). TID tracks required fewer TID weeks (median 10, IQR 7, range 4–18) than TID fellowships (median 19, range 18–20), but owing to small sample size, no statistical inferences could be made.

Pediatric TID tracks often required TID‐specific clinic (83%); all required pre‐transplant evaluation consults and TID‐specific scholarship. Two‐thirds required attendance at selection meetings. These expectations did not differ from pediatric TID fellowships (Table 2).

All 19 PID programs have exposure to TID. Among the nine programs with pediatric TID training, TID experiences for fellows not in a TID track of fellowship occurred most commonly on a separate, required TID service (60%). For others, TID experiences were integrated into the general ID consult service (22%) or offered as an elective experience (11%). Among the 10 programs that did not have an active pediatric TID training program (no fellowship or track), 4/10 (40%) indicated that TID consults are integrated into the general PID consult service, and 6/10 (60%) that a separate TID service is required of all general PID fellows.

Though all responding PID programs indicated that all fellows have some amount of TID exposure (either integrated into general PID consults or requiring TID rotations), the 10 pediatric programs without an active TID training program offered explanations relating to the low fill rate of the general PID fellowship match rate. Some noted there was a hard enough time filling the general PID fellowship, being an additional 3 years of training after pediatric residency for a less compensated specialty. One respondent noted there was an ethical obligation to train general PID clinicians since the match rate was low.

4. Discussion

We describe significant heterogeneity in the structure, funding, curriculum, and outcomes of TID training programs—TID fellowships and tracks—among both adult and pediatric programs. Importantly, we identify gaps in curriculum between prior recommendations from expert TID educators and the current training programs.

An adequate volume and diversity of TID patients is dependent on other advanced clinical services—hematologic stem cell transplantation and transplant surgery. Outside of the institutions that regularly perform a full range of these transplant services, TID training will be heterogeneous, and some fellowships may benefit from standards of supplementing clinical training. The AST IDCOP in 2010 recommended TID fellowships to consider supplemental rotations at outside institutions focused on lung transplantation and allogeneic HSCT to ensure fellows learn how to manage these less common and more complex patients [1]. Similarly, the 2015 pediatric guidance recommends pediatric TID programs at a minimum have regular HSCT and at least 2 SOT organs at their institutions, and if volume is low, programs should consider supplemental rotations with an adult program [5]. While we did not survey programs about external rotations, 20% of adult and 50% of pediatric TID fellowships did not have lung transplantation performed at their institution. This identifies an inherent problem with TID training: diverse patient exposures in TID training rely on sustaining other non‐ID clinical services, and TID training at one institution is not the same as the next. Graduates from TID tracks are less likely to have comprehensive exposure to thoracic transplantation, and only about half of fellowship or track graduates are coming from institutions that perform intestinal transplantation.

Regarding TID fellowship curriculum, we see opportunities for growth and standardization. Only 67% of adult and 75% of pediatric TID fellowship programs have distinct didactic curriculum for TID fellows, and 53% of adult and 0% of pediatric programs have distinct core competencies to evaluate TID Fellows, though 80% of adult and 50% of pediatric programs indicated they referenced either the 2010 or 2015 guidance documents when creating their fellowship. There are current initiatives within the AST IDCOP to create a foundational curriculum that can be shared among programs. Both TID fellowships and tracks would benefit from a common curriculum that helps achieve the standards set forth by previous expert recommendations. Additionally, the AST IDCOP has newly formed a working group of TID PDs to create core competencies to further standardize training.

Most graduating TID fellows are seeking clinically focused TID careers rather than research or industry, relatively few are applying for additional years of funded research, and most research experiences are retrospective or quality improvement. These findings likely represent the clinical interests of those seeking additional TID fellowship training and the inherent limitations on protected research time in one‐year training programs, which require substantial clinical time. While the prior curricular guidance recommends that adult and pediatric TID fellowships require a component of scholarship with at least an abstract submission, this is an area for growth. To promote the development of physician‐scientists in TID, programs should emphasize early research mentorship at the onset of the training program, and TID fellows interested in further research training should be guided towards funding such as the AST Fellowship Research Grants or other similar training grants through multiple NIH institutes relevant to TID (e.g., National Institute of Allergy and Infectious Disease, National Heart, Lung, and Blood Institute, National Institute of Diabetes and Digestive and Kidney Diseases, and National Cancer Institute). With current TID training limited to one additional year, protected research time to generate a competitive grant application will be limited. Our societies and training programs should determine how to support promising trainees during this critical transition from clinical training to early career faculty. The field needs to fill the gap in the TID physician‐scientist workforce with individuals able to lead teams investigating the coming unknown unknowns (e.g., xenotransplantation, new immunosuppressive agents, and new cellular therapies).

Though the field is moving towards having a defined TID training experience prior to independent practice, until there is ACGME accreditation for TID fellowships, the question remains whether a TID track is comparable to a TID fellowship. Our data support that TID fellowships offer slightly more clinical exposure than a track. Additionally, when considering the non‐consult activities required of TID specialists (e.g., selection meetings, donor calls, policy development), it is more feasible to get adequate exposure during an immersive fellowship rather than a loosely defined track during an otherwise busy general ID training program. ACGME accreditation is likely the best way to ensure consistent training. A way forward, even before ACGME accreditation, could be our society's defining clear consensus recommendations for TID fellowships and tracks. Fellowships adhering to these recommendations would set the standard of what a TID specialist's training should include. Tracks following the recommendations would not only help employers and trainees decide if they had adequate TID experience to practice independently, but track graduates could more clearly identify gaps in their training that they hope to fill during possible TID fellowships. For example, a track graduate from a program with a robust HSCT population but smaller SOT program could discuss this with prospective fellowship programs, not only allowing them to focus clinically on SOT services, but also free up time for scholarly work. This is a call to action to update TID track and fellowship standards because both training programs are valuable, particularly for adult specialists.

Pediatric TID specialists are necessary to care for some of the most vulnerable children. However, with even fewer programs, lower compensation, and longer general PID fellowships, the sub‐specialty faces challenges that likely require different solutions than adult programs. It may be more feasible to start expanding the PID TID training field by focusing on developing PID TID tracks integrated into the general PID fellowship, which is already 3 years, rather than asking fellows to spend a 4th year as a fellow. Still the PID TID field would similarly benefit from updated track and fellowship standards.

One clear limitation of this survey is the low response rate from pediatric TID fellowships and tracks, likely in part due to different recruitment methods. We attempted more targeted recruitment but were not successful. We lack an assessment of readiness to practice, which would be a key extension of our work and may include interviews of TID fellows after graduation. Further, while we describe the breadth of experiences in TID, our methods do not allow for detailed exploration of TID fellows’ clinical, scholarly, or administrative efforts; these specific data would be valuable to a program hoping to start new TID fellowship or optimize an existing fellowship to achieve the core competencies set forth by AST IDCOP, IDSA, PIDS, and IPTA.

5. Conclusion

Adult and pediatric TID subspecialty training has significant heterogeneity, and there are gaps between current programs and prior recommendations. Despite these gaps, TID fellows are contributing to the ID workforce, caring for some of the highest‐risk patients. The field will benefit by updating recommendations for designing a TID training program focusing on minimal requirements based on patient volume/mix, recommended non‐patient care activities, a standardized curriculum, and core competencies. AST, IDSA, and PIDS can facilitate collaboration among TID fellowship programs. The fellows and the patients deserve optimized and standardized expectations of graduates to ensure high‐quality, safe, innovative care.

Author Contributions

All authors have seen and approved the manuscript, contributed significantly to the work, and confirm that the manuscript has not been previously published nor is being considered for publication elsewhere.

Funding

This project was supported by an Education Innovation Grant Award; Department of Medicine University of Wisconsin–Madison.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting File 1: tid70132‐sup‐0001‐SuppMat.docx

Supporting File 2: tid70132‐sup‐0002‐SuppMat.docx

Supporting File 3: tid70132‐sup‐0003‐SuppMat.docx

Scolarici M. J., Tischendorf J., Filipiak R., et al. “Landscape of Current Transplant Infectious Disease Training Programs.” Transplant Infectious Disease 28, no. 1 (2026): e70132. 10.1111/tid.70132