Home dialysis fellowship offers a pathway for training
Click Here to Manage Email Alerts
The profession of nephrology has expanded in the last 50 years due to changes in public policy, increasing access to dialysis therapy and advancements in kidney research.
Because of this, the scope of practice for nephrologists has become more complex, as they now care for patients with multiple comorbidities who require specialized expertise. There is also an increasing demand for individualized care tailored to the patient.
To better prepare graduates for this evolving landscape, workforce training needs to incorporate pathways for interventional nephrology, onconephrology, home dialysis, cardio-renal syndrome, hepatonephrology and others.
To ensure nephrologists are adequately trained in peritoneal dialysis, the American Board of Internal Medicine (ABIM) has strengthened its educational requirements. These include PD clinic attendance, involvement in dialysis care delivery and dialysis patient training. The ABIM also encourages educational opportunities for home hemodialysis to be made available. While these changes are exciting, modifications to the current training structure may be necessary — particularly if we are to develop the next generation of researchers and teachers.
More opportunities
Opportunities for learning about home dialysis have increased. These include national conferences, longitudinal virtual mentoring, journal clubs and workshops. Journals have dedicated sections about the fundamentals of home dialysis, core topics and innovations. The American Society of Nephrology has the Home Dialysis Project, which trains professionals and trainees. These initiatives offer a range of scholarships to help trainees learn more. Companies in the dialysis industry have also developed and supported educational initiatives.
Home dialysis training
As Thomas Sydenham said, “The art of medicine was to be properly learned only from its practice and exercise.” Home dialysis training during fellowship programs varies widely. In some programs, fellows are assigned to follow up with the patients of a particular attending throughout their training years. Although longitudinal follow-up of patients on home dialysis can provide valuable learning experiences for fellows, it can be challenging to balance teaching and clinical care during comprehensive monthly visits. Additionally, most clinical patient issues are resolved prior to monthly visits by interaction between the nursing staff, patient and physician. Thus, trainees may not be able to gain visibility in this troubleshooting of home dialysis-related issues. Further, hospitalizations in patients on home dialysis have decreased and trainees may not care for many of these patients during inpatient rotations.
While we support efforts on enhancing home dialysis education, we posit that an extra year of extensive hands-on training across both PD and HHD understanding of administrative responsivities may be necessary to ensure competency for the future nephrologist who want to be an expert in this area.
The care of patients on home dialysis is a complex process involving various aspects such as timely and correct placement of dialysis access, adapting dialysis prescriptions to the patient’s clinical conditions and lifestyle, supporting patients at home and avoiding and recognizing complications early. To tackle these challenges, a home dialysis fellowship program could help optimize care by identifying critical knowledge gaps, engaging in scholarly activities and educating future nephrologists.
Home dialysis curriculum
To our knowledge, there are three medical centers with home dialysis fellowship programs in the United States: Indiana University, Vanderbilt University and Icahn School of Medicine at Mount Sinai. One barrier may be funding. Onconephrology fellowships have received local institutional support or NIH grant support, but there have been limited pathways for home dialysis. Another barrier may be the lack of faculty experts for this specialized training to take place or to develop the curriculum and workflow.
At our institution, the curricula for the programs include a comprehensive experience of inpatient, outpatient and administrative activities. The program highlights the balanced experience of initial patient assessment and training, longitudinal care on home dialysis and other aspects such as urgent-start PD.
As the home dialysis program is large with various locations and dialysis providers, trainees get to work with multiple physicians, patients and nurses. Developing quality improvement projects such as reducing culture negative peritonitis rate, adjustment of target weights or impact of annual nurse home visits is also important, as well as the opportunity to do research. We believe immersive training in home dialysis ultimately improves patient outcomes and experiences by producing expert clinicians. Leveraging institutional resources and knowledge enables this with the addition of a specialized home dialysis fellowship for some nephrologists, yielding the best results.
- References:
- ABIM - Nephrology Procedures Impact Statement Plus Rationale. https://www.abim.org/Media/0dmnxx3e/nephrology_procedures_rationale.pdf. Accessed Feb. 15, 2024.
- Advanced Renal Education Program. https://advancedrenaleducation.com/wparep/. Accessed Feb. 15, 2024.
- American Society of Nephrology: Excellence in Patient Care - Home Dialysis Project (HDP). https://epc.asn-online.org/projects/hdp/. Accessed Feb. 15, 2024.
- Cho Y, et al. Clin J Am Soc Nephrol. 2023;doi:10.2215/CJN.0000000000000272.
- End-Stage Renal Disease Treatment Choices (ETC) Model - Second Annual Evaluation Report, CMS. Published January 2024. Accessed Feb. 15, 2024.
- Home Dialysis University for fellows. https://3eaglesinc.com/hduforfellows/. Accessed Feb. 15, 2024.
- Institute of Nephrology by DaVita. https://davita.csod.com/login/render.aspx?id=instituteofnephrology. Accessed Feb. 15, 2024.
- Rosenberg ME, et al. Clin J Am Soc Nephrol. 2023;doi:10.2215/CJN.0000000000000133.
- For more information:
- Nupur Gupta, MD, and Brent W. Miller, MD, are members of the division of nephrology at Indiana University School of Medicine. They are also members of the Editorial Advisory Board for Healio | Nephrology News & Issues and can be reached at nugupta@iu.edu and bwm1@iu.edu.
Collapse
Read more about
Click Here to Manage Email Alerts