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American Journal of Kidney Diseases

Is Nephrology Fellowship Training on the Right Track?

      Even if you are on the right track, you'll get run over if you just sit there.Will Rogers
      • Applewhite A.
      • Evans T.
      • Frothingham A.
      And I Quote: The Definitive Collection of Quotes, Sayings, and Jokes for the Contemporary Speechmaker.
      Since its formation in 1981, the Accreditation Council for Graduate Medical Education (ACGME) has brought numerous improvements to fellowship training.
      Accreditation Council for Graduate Medical Education
      The ACGME at a glance.
      • Kuvin J.T.
      Accreditation Council for Graduate Medical Education initiatives improve the education of cardiology fellows.
      Nevertheless, areas of deficiency continue to exist.
      • Berns J.S.
      A survey-based evaluation of self-perceived competency after nephrology fellowship training.
      • Perazella M.A.
      Nephrology fellowship training in the 21st century: where do we stand?.
      • Kohan D.E.
      Training the next generation of nephrologists.
      • Parker M.G.
      Nephrology training in the 21st century: towards outcomes-based education.
      • Lane C.
      • Brown M.
      Alignment of nephrology training with workforce, patient, and educational needs: an evidence based proposal.
      During the past 30 years, the disease complexity of patients treated by nephrologists has increased substantially. However, many nephrology fellows still receive their dedicated clinical experience in only 1 year and in their second year continue an ambulatory clinic schedule of only 1 half-day per week. I propose that we re-evaluate the time devoted to patient case–based teaching to provide fellows with the clinical skills and experience needed to practice at a satisfactory level of competency.
      Using the American Board of Internal Medicine certifying examination in nephrology (ABIM-CEN) as one objective measure of competency, 98% of the 422 first-time takers passed in 2010.
      American Board of Internal Medicine
      First-time taker pass rates—initial certification.
      However, analysis of the lowest decile's grades shows that the ABIM-CEN passing score is only ∼60% correct answers! The ABIM states that “the majority of questions (over 75 percent) are based on patient presentations occurring in settings that reflect current medical practice. Questions requiring simple recall of medical facts are in the minority….”
      American Board of Internal Medicine
      Nephrology certification exam blueprint.
      (p1) Therefore, based on their ABIM-CEN results, the clinical knowledge of many nephrologists certified by the ABIM seems less than desirable for the specialized care of a considerable number of the patients that they are likely to see. Although one might question the relevance of the ABIM-CEN to actual patient care,
      • Brown R.S.
      The ASN In-Training Examination and the ABIM certifying examination: time for a new testing paradigm.
      there are data to suggest a correlation between performance on such examinations and the quality of care rendered.
      • Landon B.E.
      What do certification examinations tell us about quality?.
      • Holmboe E.S.
      • Wang Y.
      • Meehan T.P.
      • et al.
      Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries.
      • Chen J.
      • Rathore S.S.
      • Wang Y.
      • Radford M.J.
      • Krumholz H.M.
      Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction.
      • Norcini J.J.
      • Lipner R.S.
      • Kimball H.R.
      Certifying examination performance and patient outcomes following acute myocardial infarction.
      In a survey of nephrologists upon completion of fellowships between 2004 and 2008, Berns
      • Berns J.S.
      A survey-based evaluation of self-perceived competency after nephrology fellowship training.
      found multiple clinical areas in which little or no training led respondents to perceive that they lacked self-competence. This criticism is all the more telling because training programs must document that their fellows receive formal instruction in a comprehensive curriculum.
      ACGME program requirements for graduate medical education in nephrology.
      ACGME program requirements for graduate medical education in nephrology (internal medicine).
      Quite likely, prescribed lectures fail to achieve the goal of translating such information into patient care situations, leading graduates to recognize significant gaps in their clinical experience and perception of competence.
      • Berns J.S.
      A survey-based evaluation of self-perceived competency after nephrology fellowship training.
      Subjectively, as a clinical chief of nephrology for 38 years and a training program director until 2009, I am concerned that current trainees perform less complete patient examinations than in the past (eg, how often do fellows describe the optic fundi, even in patients with hypertension?), and many of my colleagues believe similarly.
      • Whitcomb M.E.
      Internal medicine residency redesign: time to take stock.
      • Sarosi G.A.
      On being a doctor: attending rounds.
      • Oren O.
      Discovery at the bedside.
      Verghese et al
      • Verghese A.
      • Brady E.
      • Kapur C.C.
      • Horwitz R.I.
      The bedside evaluation: ritual and reason.
      argue that the bedside evaluation as “a healing ritual and a powerful diagnostic tool” must be learned through apprenticeship, but often is bypassed with imaging technology, computer modules, and simulated virtual patients. The expansion of information over the years has raised the minimum base of clinical medical knowledge beyond the scope of the time currently allotted to trainees for patient contact.
      What has not changed during the past 30 years is the ACGME requirement that a minimum of only 12 months of the 2-year fellowship in nephrology be devoted to clinical experiences, with a half-day per week in an ambulatory continuity clinic in the second year.
      • Kuvin J.T.
      Accreditation Council for Graduate Medical Education initiatives improve the education of cardiology fellows.
      ACGME program requirements for graduate medical education in nephrology.
      No added time has been required to allow for increasing dialysis and transplant exposure or provide more experience with outpatients, whose care consumes a greater proportion of nephrologists' time than in the past. Extending the required fellowship training time beyond 2 years is unlikely to occur, primarily because of financial considerations. Furthermore, an ACGME requirement mandates that all fellows have dedicated nonclinical research time, and 50% of graduating fellows must demonstrate research productivity.
      ACGME program requirements for graduate medical education in nephrology.
      ACGME program requirements for graduate medical education in nephrology (internal medicine).
      This requirement detracts from the time available to train future clinicians who will not pursue careers that include research. Likewise, minimum research requirements for faculty
      ACGME program requirements for graduate medical education in nephrology.
      ACGME program requirements for graduate medical education in nephrology (internal medicine).
      promote desirable scholarship, but with the unintended consequence of devaluing clinical faculty and decreasing the incentive for direct clinical supervision and teaching of fellows in favor of research and publications, even in clinically oriented programs.
      The American Society of Nephrology In-Training Examination (ASN-ITE) appears to have detected a serious shortcoming in clinical knowledge gained by fellows during the second or third year of training. This examination was created to mirror the ABIM-CEN, with questions “written in a case-based vignette format to be compatible with real-life clinical experiences.”
      • Rosner M.H.
      • Berns J.S.
      • Parker M.
      • et al.
      ASN In-Training Examination Committee
      Development, implementation, and results of the ASN In-Training Examination for fellows.
      In 2009, graduating fellows taking the first ASN-ITE had a mean score of 69%, only 5% higher than the mean of 64% achieved by first-year fellows.
      • Rosner M.H.
      • Berns J.S.
      • Parker M.
      • et al.
      ASN In-Training Examination Committee
      Development, implementation, and results of the ASN In-Training Examination for fellows.
      In 2010 and again in 2011, graduating fellows, most of whom had taken the examination as first-year fellows, fared no better, with 375 first-year fellows averaging 63% ± 9% (SD); 391 second-year fellows, 68% ± 8%; and 28 third-year and higher fellows, 69% ± 7%. Thus, there has been little to no improvement in fellows' performance gained during the 3 years of ASN in-training testing, with about half the graduating trainees still answering only two-thirds of clinical questions correctly. Moreover, improvement of only 5% during the second year and an additional 1% in the third year of their fellowships should be considered insufficient because repeated testing with the same examination format alone would be expected to increase scores by a “practice effect” of about 0.5-1.0 standard deviations,
      • Benedict R.H.B.
      • Zgaljardic D.J.
      Practice effects during repeated administrations of memory tests with and without alternate forms.
      • Bartels C.
      • Wegrzyn M.
      • Wiedl A.
      • Ackermann V.
      • Ehrenreich H.
      Practice effects in healthy adults: a longitudinal study on frequent repetitive cognitive testing.
      or 4%-8% for this test.
      In order to remedy this deficiency of training in the second year, I suggest that program directors increase the minimum clinical experience to 18 months and supervised ambulatory clinic time be doubled to 2 half-days per week, at least for fellows not committed to research careers (Table 1). Areas in which perceived weaknesses in training have been identified
      • Berns J.S.
      A survey-based evaluation of self-perceived competency after nephrology fellowship training.
      • Perazella M.A.
      Nephrology fellowship training in the 21st century: where do we stand?.
      • Kohan D.E.
      Training the next generation of nephrologists.
      should be emphasized, with faculty supervision of the fellows' clinical activities as an important means to achieving success.
      • Whitcomb M.E.
      Internal medicine residency redesign: time to take stock.
      Scholarly activity in the form of core lectures, journal clubs, research conferences, and quality assessment should be incorporated within the program, but more than a brief nonclinical research experience would need an added fellowship year or more for those pursuing academic research careers. A study has already shown that a dedicated clinical training program with testing and feedback is able to improve internal medicine residents' in-training examination performance and patient outcomes.
      • Mathis B.R.
      • Warm E.J.
      • Schauer D.P.
      • et al.
      A multiple choice testing program coupled with a year-long elective experience is associated with improved performance on the internal medicine in-training examination.
      • Reynolds E.E.
      Fostering educational innovation through measuring outcomes.
      As a proof-of-principle test, the ASN-ITE could be programmed to track the clinical time spent by graduating fellows to document whether increased clinical experience promotes a significant improvement in knowledge over the second year as measured by objective testing. If that is proved to be the case, I propose that the ACGME set an 18-month clinical experience and 2 half-day clinics per week as a minimum nephrology training requirement.
      Table 1Current Requirements and Proposed Revisions for Nephrology Fellowship Training
      Source for current fellowship requirements: Accreditation Council for Graduate Medical Education.
      ACGME program requirements for graduate medical education in nephrology.
      ACGME program requirements for graduate medical education in nephrology (internal medicine).
      Current Fellowship (2 y)Proposed Clinical Fellowship (2 y)Proposed Research and Clinical Fellowship (3 y)
      Year 1Year 2Year 3
      Minimum clinical experience12 mo18 mo12 mo2-3 mo2-3 mo
      Minimum ambulatory clinic time (in half-days/wk for the periods shown)24 mo of continuity clinic experience; ≥3 mo of transplant care24 mo of continuity clinic experience; ≥3 mo of transplant care; 9-12 mo of electives (general nephrology or vascular access, diabetes, urology, etc)12 mo of continuity clinic experience; ≥3 mo of transplant care12 mo of continuity clinic experience9-12 mo of electives (general nephrology or vascular access, diabetes, urology, etc)
      Interventional procedures (native kidney & transplant kidney biopsies & central venous dialysis catheter insertions)Required for all fellows; minimum no. unspecifiedNot required; fellows may elect to certify (involves satisfactorily performing a minimum specified no. of procedures [eg, 5])Not required; fellows may elect to certify (involves satisfactorily performing a minimum specified no. of procedures [eg, 5])
      To accommodate this change for research fellows who also desire clinical ABIM certification, I would favor adopting an alternate pathway with an additional year of training (Table 1). A 3-year program would allow spreading additional clinical experience over the second and third research years while still meeting the nonclinical research time expected by most grant funding sources. Such a 3-year option, already favored by many training program directors, is not permitted by current ACGME regulations, which limit recognized fellowship training to 2 years.
      ACGME program requirements for graduate medical education in nephrology (internal medicine).
      This proposed fellowship program should foster better clinical training, particularly of research fellows who subsequently decide to pursue clinical careers with little research productivity.
      Interventional procedures—kidney biopsies and central venous dialysis catheter insertions—are a requirement for all nephrology fellows,
      ACGME program requirements for graduate medical education in nephrology.
      yet there is no minimum number of these procedures specified by the ACGME to document competency despite the significant risk such procedures entail. Reaching consensus may be difficult,
      • Parker M.G.
      Nephrology training in the 21st century: towards outcomes-based education.
      • Berns J.S.
      • O'Neill W.C.
      Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs.
      • Kohan D.E.
      Procedures in nephrology fellowships: time for change.
      but we need to protect patients by ensuring a sufficient training experience for fellows certified to perform invasive procedures. I favor an alternative that removes the procedural requirements for all fellows. This option makes sense because only about half the nephrology graduates continue to perform these procedures after fellowship.
      • Lane C.
      • Brown M.
      Alignment of nephrology training with workforce, patient, and educational needs: an evidence based proposal.
      This would help training programs that have difficulty providing adequate numbers of procedures to train every fellow while ensuring that those credentialed to perform interventional procedures have been adequately prepared to do so safely.
      In summary, we cannot confirm that we are ensuring the highest quality clinical nephrology training, particularly in the second year of fellowship, based on results of ABIM and ASN examinations and graduate fellows' self-perceptions. To achieve that goal, training program directors should increase the time required for patient case–based exposure and ambulatory clinics within the current 2-year fellowship, add a new alternative 3-year program for research fellows, and specify minimum numbers of interventional procedures for credentialing fellows until better outcome measures become available.

      Acknowledgements

      Financial Disclosure: The author declares that he has no relevant financial interests.

      References

        • Applewhite A.
        • Evans T.
        • Frothingham A.
        And I Quote: The Definitive Collection of Quotes, Sayings, and Jokes for the Contemporary Speechmaker.
        in: St Martin's Press, New York, NY1992: 7
        • Accreditation Council for Graduate Medical Education
        The ACGME at a glance.
        (Accessed November 18, 2011)
        • Kuvin J.T.
        Accreditation Council for Graduate Medical Education initiatives improve the education of cardiology fellows.
        Circulation. 2008; 118: 525-531
        • Berns J.S.
        A survey-based evaluation of self-perceived competency after nephrology fellowship training.
        Clin J Am Soc Nephrol. 2010; 5: 490-496
        • Perazella M.A.
        Nephrology fellowship training in the 21st century: where do we stand?.
        Clin J Am Soc Nephrol. 2010; 5: 387-389
        • Kohan D.E.
        Training the next generation of nephrologists.
        Clin J Am Soc Nephrol. 2011; 6: 2564-2566
        • Parker M.G.
        Nephrology training in the 21st century: towards outcomes-based education.
        Am J Kidney Dis. 2010; 56: 132-142
        • Lane C.
        • Brown M.
        Alignment of nephrology training with workforce, patient, and educational needs: an evidence based proposal.
        Clin J Am Soc Nephrol. 2011; 6: 2681-2687
        • American Board of Internal Medicine
        First-time taker pass rates—initial certification.
        (Accessed November 18, 2011)
        • American Board of Internal Medicine
        Nephrology certification exam blueprint.
        (Accessed November 18, 2011)
        • Brown R.S.
        The ASN In-Training Examination and the ABIM certifying examination: time for a new testing paradigm.
        Clin J Am Soc Nephrol. 2010; 5: 1513-1517
        • Landon B.E.
        What do certification examinations tell us about quality?.
        Arch Intern Med. 2008; 168: 1365-1367
        • Holmboe E.S.
        • Wang Y.
        • Meehan T.P.
        • et al.
        Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries.
        Arch Intern Med. 2008; 168: 1396-1403
        • Chen J.
        • Rathore S.S.
        • Wang Y.
        • Radford M.J.
        • Krumholz H.M.
        Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction.
        J Gen Intern Med. 2006; 21: 238-244
        • Norcini J.J.
        • Lipner R.S.
        • Kimball H.R.
        Certifying examination performance and patient outcomes following acute myocardial infarction.
        Med Educ. 2002; 36: 853-859
      1. ACGME program requirements for graduate medical education in nephrology.
        (Accessed November 21, 2011)
      2. ACGME program requirements for graduate medical education in nephrology (internal medicine).
        (Accessed November 21, 2011)
        • Whitcomb M.E.
        Internal medicine residency redesign: time to take stock.
        Ann Intern Med. 2010; 153: 759-760
        • Sarosi G.A.
        On being a doctor: attending rounds.
        Ann Intern Med. 2010; 153: 482
        • Oren O.
        Discovery at the bedside.
        Ann Intern Med. 2011; 155: 643
        • Verghese A.
        • Brady E.
        • Kapur C.C.
        • Horwitz R.I.
        The bedside evaluation: ritual and reason.
        Ann Intern Med. 2011; 155: 550-553
      3. Subspecialty internal medicine fellowship programs.
        (Accessed November 21, 2011)
        • Rosner M.H.
        • Berns J.S.
        • Parker M.
        • et al.
        • ASN In-Training Examination Committee
        Development, implementation, and results of the ASN In-Training Examination for fellows.
        Clin J Am Soc Nephrol. 2010; 5: 328-334
        • Benedict R.H.B.
        • Zgaljardic D.J.
        Practice effects during repeated administrations of memory tests with and without alternate forms.
        J Clin Exp Neuropsychol. 1998; 20: 339-352
        • Bartels C.
        • Wegrzyn M.
        • Wiedl A.
        • Ackermann V.
        • Ehrenreich H.
        Practice effects in healthy adults: a longitudinal study on frequent repetitive cognitive testing.
        BMC Neurosci. 2010; 11: 118
        • Mathis B.R.
        • Warm E.J.
        • Schauer D.P.
        • et al.
        A multiple choice testing program coupled with a year-long elective experience is associated with improved performance on the internal medicine in-training examination.
        J Gen Intern Med. 2011; 26: 1253-1257
        • Reynolds E.E.
        Fostering educational innovation through measuring outcomes.
        J Gen Intern Med. 2011; 26: 1241-1242
      4. Nephrology fellowship programs FAQ.
        (Accessed November 21, 2011)
        • Berns J.S.
        • O'Neill W.C.
        Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs.
        Clin J Am Soc Nephrol. 2008; 3: 941-947
        • Kohan D.E.
        Procedures in nephrology fellowships: time for change.
        Clin J Am Soc Nephrol. 2008; 3: 931-932