ASN Data Bytes: Academics Offer Diverging Opinions on Nephrology Procedures

By Kurtis Pivert

A recent ASN Flash Poll found differing opinions among academic nephrologists over procedures, specifically catheter placements and kidney biopsies. Stewart Lecker, MD, PhD, on behalf of the ASN Workforce and Training Committee, developed the survey to capture current perspectives on procedural competence among training program directors (TPDs), associate TPDs (APDs), and division chiefs.

The findings of the poll concluded that no clear consensus emerged on assessing procedural competence, fellows’ capability to independently perform biopsies and/or line placements, or whether they should remain core to the specialty. 

Procedural Competence Core to Nephrology? 

Most division chief respondents indicated both procedures should remain requirements for Accreditation Council for Graduate Medical Education (ACGME) and American Board of Internal Medicine (ABIM). However, 63% of TPD/APD respondents disagreed over catheter placements, indicating they should no longer be mandatory for board certification (Figure 1). 

Figure 1: Should catheter placements and kidney biopsies remain ACGME and ABIM requirements?

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The programs whose fellows performed fewer procedures across the 2-year ACGME-accredited training period were less likely to support retaining line placement and kidney biopsies as core practice areas of the specialty (Figures 2 and 3). 

Figure 2: Range of Minimum/Maximum Line Placements by Fellowship Year

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Figure 3: Range of Minimum/Maximum Kidney Biopsies by Fellowship Year

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Are Fellows Ready for Independent Practice?  

Most TPD/APD respondents indicated their graduated fellows were capable to perform the procedures independently (catheters 65%, biopsies 68%). Yet 20% and 16% lacked confidence in their fellows’ ability to perform line placements and biopsies, respectively. 

Of the 12 program directors who lacked confidence in their fellows’ ability to competently place catheters, 10 indicated the procedure should not remain core to the specialty. All 10 who were not confident in their fellows’ competency in kidney biopsies felt it should not remain an ACGME and ABIM requirement. 

The range of procedures performed varied across respondents, with some indicating minimums of 0–25 catheter placements and 0–20 biopsies over 2 years (Figures 2 and 3). 

How is Competence Assessed?

Competence in both procedures is mostly evaluated using a set number, although the target varies for both line placements (median 5, range 2–12) and kidney biopsies (median 8, range 0–20). Whereas fellows were mostly assessed by nephrology faculty on kidney biopsies, catheter competence was overseen by a mix of nephrologists, intensivists, and radiologists. 

Limitations

The analysis is limited by a low overall response rate (23.4% for TPDs/APDs; 19.3% for division chiefs), although this is still within the range for physician surveys. Likewise, the data is also limited by self-selection and non-response biases. Directions for future research include a more detailed look at these milestones and how they are taught and evaluated; how competence is assessed at both teaching and private institutions; and who (nephrologist or other specialist) typically performs these procedures in individual clinical settings.

The full ASN Data Brief is available here

What workforce data gaps or questions do you think should be addressed? Email your suggestions to workforce@asn-online.org

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Kurtis Pivert
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A recent ASN Flash Poll found differing opinions among academic nephrologists over procedures, specifically catheter placements and kidney biopsies. Stewart Lecker, MD, PhD, on behalf of the ASN Workforce and Training Committee, developed the survey to capture current perspectives on procedural competence among training program directors (TPDs), associate TPDs (APDs), and division chiefs.

The findings of the poll concluded that no clear consensus emerged on assessing procedural competence, fellows’ capability to independently perform biopsies and/or line placements, or whether they should remain core to the specialty. 

Procedural Competence Core to Nephrology? 

Most division chief respondents indicated both procedures should remain requirements for Accreditation Council for Graduate Medical Education (ACGME) and American Board of Internal Medicine (ABIM). However, 63% of TPD/APD respondents disagreed over catheter placements, indicating they should no longer be mandatory for board certification (Figure 1). 

Figure 1: Should catheter placements and kidney biopsies remain ACGME and ABIM requirements?

Figure1_0.png

The programs whose fellows performed fewer procedures across the 2-year ACGME-accredited training period were less likely to support retaining line placement and kidney biopsies as core practice areas of the specialty (Figures 2 and 3). 

Figure 2: Range of Minimum/Maximum Line Placements by Fellowship Year

Figure2A_0.png

Figure2B_0.png

Figure 3: Range of Minimum/Maximum Kidney Biopsies by Fellowship Year

Figure3A_0.png

Figure3B_0.png

Are Fellows Ready for Independent Practice?  

Most TPD/APD respondents indicated their graduated fellows were capable to perform the procedures independently (catheters 65%, biopsies 68%). Yet 20% and 16% lacked confidence in their fellows’ ability to perform line placements and biopsies, respectively. 

Of the 12 program directors who lacked confidence in their fellows’ ability to competently place catheters, 10 indicated the procedure should not remain core to the specialty. All 10 who were not confident in their fellows’ competency in kidney biopsies felt it should not remain an ACGME and ABIM requirement. 

The range of procedures performed varied across respondents, with some indicating minimums of 0–25 catheter placements and 0–20 biopsies over 2 years (Figures 2 and 3). 

How is Competence Assessed?

Competence in both procedures is mostly evaluated using a set number, although the target varies for both line placements (median 5, range 2–12) and kidney biopsies (median 8, range 0–20). Whereas fellows were mostly assessed by nephrology faculty on kidney biopsies, catheter competence was overseen by a mix of nephrologists, intensivists, and radiologists. 

Limitations

The analysis is limited by a low overall response rate (23.4% for TPDs/APDs; 19.3% for division chiefs), although this is still within the range for physician surveys. Likewise, the data is also limited by self-selection and non-response biases. Directions for future research include a more detailed look at these milestones and how they are taught and evaluated; how competence is assessed at both teaching and private institutions; and who (nephrologist or other specialist) typically performs these procedures in individual clinical settings.

The full ASN Data Brief is available here

What workforce data gaps or questions do you think should be addressed? Email your suggestions to workforce@asn-online.org