Innovative curriculums, new home dialysis training attract more fellows to nephrology
Click Here to Manage Email Alerts
To get fellows more engaged in the prospect of nephrology as a specialty, Steven Fishbane, MD, and Hitesh H. Shah, MD, said they had to think outside the box.
The nephrologists, from the division of kidney diseases and hypertension in the department of medicine at North Shore University Hospital and Long Island Jewish Medical Center and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York, developed a nephrology curriculum that offers learning opportunities to nephrology fellows on a variety of subspecialities, including onconephrology, glomerular diseases, transplant nephrology, obstetric nephrology and medical directorship of dialysis centers.
Source: American Society of Nephrology
The reaction from fellows, Fishbane told Healio | Nephrology News & Issues, has been universally positive.
“This past year, I supervised an outstanding fellow who is our first to do two tracks — one in obstetric nephrology and one on dialysis medical directorship,” Fishbane said. “She loved it and just last week presented lectures to our group on both subjects, sharing her newly acquired expertise.
“The key aspect is during the actual nephrology fellowship. The fellow gets specialized expertise without extra time for training,” he said.
In an article by Shah, Fishbane and colleagues detailing the diverse fellowship training of the Hofstra/Northwell program, the authors wrote that advances in subspecialization in nephrology required updates in fellowship training. “Traditionally, nephrology fellowships have trained fellows to practice as general nephrologists,” Shah and colleagues wrote. “The focus on generalized nephrology training was sensible because a nephrologist in practice was able to manage the broad range of kidney issues that they were confronted with.
“Over the past decade, however, with the advent of novel therapeutics and innovations in nephrology and other subspecialties, nephrology care has become increasingly complex,” Shah and colleagues wrote. They added, “An argument may be made that with additional training, all nephrologists could keep pace with the rapid expansion in required knowledge. But the reality is that the number of physicians choosing to enter nephrology fellowships is currently limited and an increased length of training in this environment could be challenging or unattractive to potential candidates.”
Fishbane said he and colleagues are looking at other subspecialities for their education programs, which run from 6 to 18 months and usually start in the second year of the fellowship. Possible tracks include kidney stones, cardionephrology, hypertension, clinical trials and home dialysis.
“I’m interested in a broader business of nephrology track, but we are considering the idea of making it part of our general nephrology curriculum,” Fishbane said. “Every fellow would learn not just about the medicine and science but also about the business aspects — so important for success in this rapidly changing environment.”
Home dialysis training
Fishbane’s interest in developing a home dialysis track echoes what the kidney community has said for some time: Few nephrology programs provide fellows with access to home dialysis as part of their training. In a survey done among 110 nephrology trainees with at least 1 year of nephrology fellowship completed, most said they felt only moderately prepared to discuss the home dialysis option with patients. “ ... [O]our study clearly highlights that educational resources and clinical training opportunities do not universally exist during nephrology training in the United States,” Nupur Gupta, MD, with the division of nephrology in the department of medicine at Indiana University School of Medicine, and colleagues wrote. “Further, even when those resources are present, the comfort level and overall preparedness for home dialysis remain moderate for [peritoneal dialysis] PD and low for [home hemodialysis] HHD. Robust efforts redesigning the curriculum, incorporating new learning technologies, and ensuring home dialysis clinical competencies before graduation are initial steps forward toward improving the effectiveness of home dialysis education during nephrology training.”
In a survey among academic nephrology program directors, the results were similar. Most noted that fellows were ill-equipped to discuss home dialysis with patients.
“Only 72% [of division chiefs] and 30% of program directors reported that, on graduation, every fellow in their fellowship program could provide peritoneal dialysis and home hemodialysis without supervision, respectively,” Yuvaram N.V. Reddy, MBBS, MPH, of the renal-electrolyte and hypertension division of the Perelman School of Medicine at the University of Pennsylvania, and colleagues wrote in a research letter published in Kidney Medicine. In the survey, 74% of the nephrology program directors also said a virtual home dialysis mentorship program was needed to improve fellowship training.
Kidney community responds
Efforts have been underway in the kidney community to improve curriculum requirements for home dialysis. The American Society of Nephrology formed a home dialysis steering committee in July 2021 to identify and prioritize gaps in training, education and advocacy in home dialysis. “Nephrology trainees have long cited a lack of education and exposure to home hemodialysis and peritoneal dialysis during training as a major educational gap,” according to an ASN press release. To address the issue, ASN entered into an agreement with the CDC to establish a pilot home dialysis course for nephrology fellows, including a 12-month virtual education program, and in March 2023 announced a collaboration with the Home Dialysis University (HDU) “to improve nephrology trainees’ knowledge, proficiency and exposure to home dialysis therapies,” according to the release.
Those efforts, along with work by an ASN task force looking at ways to improve fellowship training, lead to new requirements from the American Board of Internal Medicine (ABIM) that take effect in July 2024 for nephrology training programs to provide more training for fellows about home dialysis. The expanded curriculum requires visits to eight peritoneal dialysis sessions and education on home hemodialysis.
“The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies and home hemodialysis which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies,” Rudolph A. Rodriguez, MD, of the department of medicine at the University of Washington, Seattle and the VA Puget Sound Health Care System, and colleagues wrote in the American Journal of Kidney Diseases.
“The [ABIM] heard loud and clear that the requirement for home dialysis needed to be strengthened, specifically regarding the initial certification exam,” Matthew A. Sparks, MD, a co-author on the article with Rodriguez and associate professor of medicine at Duke University School of Medicine and program director for its nephrology fellowship program, told Healio | Nephrology News & Issues. “While the requirement to achieve competency in peritoneal dialysis has been part of the ABIM procedural requirements since 1994, national surveys of nephrology fellows continue to show that nearly half of graduating fellows do not feel well-trained or competent in managing patients on chronic peritoneal dialysis,” he said.
Some of the ABIM guidelines for nephrology date back to 1988, when the board defined essential procedural skills in nephrology, and “candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis and percutaneous renal biopsy,” Rodriguez and colleagues wrote about the process for updating the home dialysis requirements for ABIM certification.
Gupta, along with fellow University of Indiana nephrologist Brent Miller, MD, have developed a fellowship program for home dialysis. “We believe immersive training in home dialysis ultimately improves patient outcomes and experiences by producing expert clinicians,” they wrote in an editorial published in Healio | Nephrology News & Issues.
Future of nephrology
The strong interest in making nephrology a more attractive specialty to fellows started in April 2022 when ASN launched its Task Force on the Future of Nephrology. ABIM and the Accreditation Council for Graduate Medical Education (ACGME) had asked ASN to form the task force to assess core competencies and identify gaps in nephrology training programs. The recommendations of the task force were detailed in an article in the Clinical Journal of the American Society of Nephrology. “Since the article in February 2023, ASN has continually worked to implement the recommendations by taking a multifaceted approach,” Robert S. Hoover, Jr., MD, FASN, chair of the workforce and training committee, told Healio | Nephrology News & Issues. “During the work of the task force there were multiple meetings with ABIM and ACGME to give ASN’s input on revisions to procedural competencies for fellowship training. Subsequently ABIM and ACGME issued draft proposals of those revisions.
“In June 2023, ASN responded to draft proposals from both ABIM and ACGME on the revisions to procedural competencies for initial certification in nephrology as well as the updated nephrology fellowship program requirements, respectively. Most of ASN’s recommendations were reflected in the final versions of both documents,” Hoover said.
The inclusion of home dialysis in the ACGME fellowship requirements “now accurately reflect the core competencies needed for fellowship training,” Hoover said. “However, in keeping with the recommendations of the task force we believe that fellows should be able to develop individualized pathways during the second year of the fellowship, allowing them to gain extra exposure to a subspecialty of nephrology such as onconephrology or critical care nephrology,” he said.
Hoover said he was optimistic that the changes to fellowship training would increase interest in nephrology. “I believe that increasing the breadth and scope of what it means to be a nephrologist will attract more trainees into nephrology. Knowing that nephrology can be both cerebral and procedural will pique the interest of trainees. As we continue to implement these recommendations of the Task Force on the Future of Nephrology, we expect that the appreciation of nephrology as an amazing career path will continue to grow,” he said.
- References:
- American Society of Nephrology. Home Dialysis University collaborate to enhance home therapies education for nephrology fellows. https://www.asn-online.org/about/press/releases/ASN_PR_20230320_FINALasnhdu3.17.23.pdf. Published March 20, 2023. Accessed June 21, 2024.
- Gupta N, et al. Am. Jrnl Kid Dis. 2020;doi:10.1053/j.ajkd.2020.09.014.
- Gupta N, et al. Home dialysis fellowship offers a pathway for training. https://www.healio.com/news/nephrology/20240305/home-dialysis-fellowship-offers-a-pathway-for-training. Accessed June 20, 2024.
- Reddy YNV, et al. Kid Med. 2023;doi:10.1016/j.xkme.2023.100629.
- Rodriguez RA, et al. Am J Kidney Dis. 2024;doi:10.1053/j.ajkd.2024.03.014.
- Rosenberg ME, et al. Clin J Am Soc Nephrol. 2023.doi:10.2215/CJN.0000000000000133.
- Shah HH, et al. Am. J Kidney Dis. 2023;doi:10.1053/j.ajkd.2023.05.006.
- For more information:
- Steven Fishbane, MD, can be reached at sfishbane@northwell.edu.
- Nupur Gupta, MD, can be reached at nugupta@iu.edu.
- Matthew A. Sparks, MD, can be reached at matthew.sparks@duke.edu.