*Purpose: The American Society of Transplant Surgeons (ASTS) provides a framework for the training and development of a competent transplant surgery workforce. Practice-readiness and phase-in into practice after fellowship have never been evaluated. The purpose of this study is to evaluate surgeon expectations for practice readiness early after fellowship.

*Methods: The Transplant Accreditation & Certification Council (TACC) established by the ASTS developed a survey instrument that was adapted to junior surgeons (JS, 1-6 years into practice) and senior surgeons (SS, 6-15 years). The survey targeted demographics, practice setting, readiness and expectations at start of practice in relation to knowledge and competencies, support systems during transition, and opportunities to enhance practice entry.

*Results: The survey was sent to 381 JS and 814 SS surgeons who are members of the ASTS. Among JS 111 responded and SS 161 responded. Autonomy in non-complex liver transplant (LTxp) was expected in 83% among SS and 79% with JS (p=0.2) vs 9% among SS and 27% for JS in complex LT (p<0.01). Autonomy in routine kidney transplant (KTxp) was expected in 100% among SS and 98% with JS (p=0.1) vs 94% among SS and 65% for JS in complex KT (p<0.01). Living donor nephrectomy was expected among 54% of SS vs 79% of JS (P<0.01). Autonomy in kidney-pancreas Txp was expected in 30% among SS vs 56% with JS (p<0.01). With multiorgan deceased donor organ recovery, autonomy was expected among 64% of SS and 89% of JS (P<0.01). Ability to vet organ donor offers was expected among 84% of SS and 77% of JS (P<0.05). Managing complex intra-op decisions was expected among 40% of SS and 79% of JS (p<0.01). Working in multidisciplinary setting was expected among 99% of SS and 98% of JS (p=0.2). Ability to achieve work-life balance was at 53% among JS while JS insights into this was noted by 85% of SS (p<0.01). Familiarity with UNOS/OPTN policies was expected among 99% of SS, while awareness with such policies was noted among 48% of JS (p<0.01). 88% of SS stated they provide clinical mentorship, while 70% of JS stated they received mentorship (p<0.01). Second surgeon proctoring was stated by 75% of SS, but acknowledged by 58% of JS (p<0.05). Structured on-boarding was acknowledged by 41% of SS as opposed to 21% of JS (P<0.01). 78% of SS stated they provide surgeon specific feedback on quality outcomes and process improvement, while 36% of JS acknowledge receiving such feedback (p<0.01). 87% of SS felt a transition to practice process/period is needed for full autonomy, compared to 46% among JS (p<0.01).

*Conclusions: There are significant disparities in expectations of SS and insights of JS into achieving autonomy with full competence in early practice and knowledge of some essential aspects of transplant practice. There is also a difference in perceptions on the value of a structured on-boarding program after fellowship. Defining competencies achieved during training, and a structured transition into practice are deemed valuable. Communicating expectations among fellow trainees, JS and SS is needed to align with essential services in clinical practice. A limitation of the study is the response rate which may limit generalization to all practice settings.

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