Mandating Procedural Competency in Nephrology Fellowship: Necessary or a Loss of Time?

In this article, fellows Arpita Basu, MD, MPH, and Rob Rope, MD, address the advantages and disadvantages of mandating procedural competency in nephrology fellowship.

Too little time, too much to learn?

Procedures have played an integral part throughout the practice of nephrology. However, it is time to evaluate this tradition. Competency in our “core” procedures (e.g., kidney biopsies and non-tunneled hemodialysis catheter placement) is required by the Accreditation Council for Graduate Medical Education (ACGME) for graduation from nephrology fellowship, although there is no minimum requirement for the number of procedures to be performed (1). Between juggling consults, racing through clinics, performing research, or getting some reading done, is there any time left for procedures?

In the “real” world, owing to time constraints, turf battles, and proficiency concerns, only a limited number of nephrologists perform a few select procedures. These procedures are now increasingly performed by other specialties or by interventional nephrologists. This raises a nagging question: Is expertise in these procedures vital for a budding nephrologist?

If we are to maintain these competencies, it must be recognized that our national performance is suboptimal. Surveys conducted in the past decade have highlighted the limited training in procedures obtained during fellowship and the discomfort many independent nephrologists feel while performing them. In 2008, a survey by Berns and O’Neil showed that while core procedures were a part of almost all fellowship curriculums, the training obtained was not consistent across programs (2). Other studies have reported that 33% of practicing nephrologists did not feel comfortable placing temporary HD catheters, and of the graduating fellows, 25% had not placed a temporary IJ catheter, 15% had not placed a femoral catheter, and 5% had never done a renal biopsy (3,4). With ACGME proficiency requirements still in place, how is it that so many fellows graduate without performing the required procedures? If these skills are mere checks in checkboxes essential to graduation, isn’t it time for a curriculum revision?

Given our current procedural performance, our increasingly busy lives in fellowship, and the reality that most fellows will never or rarely use these skills after graduation, perhaps it would be more valuable to devote that time to learning how to interpret renal imaging or pathology, or focusing on just performing kidney biopsies if desired? At present, the incorporation of imaging and training in kidney biopsy performance appears heterogeneous across fellowships (2). As a result, the command and competency in their use is not equal across the majority of fellows.

Interventional nephrology is a growing subspecialty focused on mastery of the procedural portion of nephrology. The American Society of Diagnostic and Interventional Nephrology (ASDIN) offers resources for nephrologists interested in developing finesse performing procedures (5). The ASDIN requires nephrologists to have completed each procedure as a primary performer a minimum of 25 times to be certified. With these resources available, nephrologists whose jobs require performing procedures can receive the necessary training and certification, just as providers obtain Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certifications when needed.

In the end, while kidney biopsies may still add value for nephrologists in training, temporary hemodialysis catheter placement can be done away with. With the option of getting the necessary certifications for procedures available for those who use them regularly, it is time for the core curriculum to be more in line with current nephrology practices.

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Procedures are a core of nephrology

Procedural milestones define the history of nephrology. The first successful dialysis used a rotating-drum kidney with sausage casings. The refinement of shunts made outpatient dialysis a reality. The development of percutaneous biopsies enabled the routine diagnosis and treatment of specific kidney pathologies. Statistics, however, cannot describe why nephrologists in training must hone skills in our “core” procedures.

We provide life-saving dialysis at critical times and must maintain control of how, and when, catheters are placed. Our expertise in placing catheters not only ensures we can provide timely therapy without waiting for other providers, but it helps us understand what patients undergo when a stiff catheter is inserted into their neck or groin. Furthermore, limiting the placement of temporary catheters by other specialties (e.g., our ICU and surgical colleagues) may reduce the number of inappropriately placed or unused catheters. Likewise, as physicians who prescribe risky immunosuppression to fight potentially life-threatening disorders, we must know not just the risks and benefits on paper, but how important trying for a third or fourth pass is.

Relinquishing control over these procedures and reducing our scope of practice may begin a slippery slope toward the elimination of these procedures completely. Indeed, as shown in Figure 1, reducing our procedural experience could further reduce a fellow’s confidence and generate greater avoidance of procedures (6). While the ASDIN offers compelling training opportunities, reducing our competencies early on in fellowship may diminish interest in interventional nephrology as a field and thus reduce the number of interventional nephrologists in practice. The loss of procedures may also affect a program’s finances by limiting procedural revenue. Last, our current lack of procedures is a factor limiting trainee interest in nephrology (7). Preserving our procedure scope is therefore of paramount importance in ensuring the security of the future nephrology workforce.

Figure 1.

Interplay between frequency and confidence in performing procedures, a vicious cycle whereby performing procedures infrequently leads to loss of confidence, which leads to procedure avoidance.

Courtesy: Mendelssohn DC. Should nephrologists take a larger role in interventional nephrology, and should central line insertion remain a requirement of nephrology residency training? A debate. Can J kidney Health Dis 2015; 2:10–12.

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Going forward

There is an ongoing debate about which, if any, procedural competencies should continue to be mandated in nephrology training (8,9). Here, we have attempted to highlight views from both sides of this discussion. However, we are of the opinion that if these competencies are to be maintained, our trainees would benefit from the expansion of evidence-based educational modalities (e.g., simulation programs for catheter placement and biopsies) to ensure that we provide quality care throughout the spectrum of nephrology practice.

References

1. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Nephrology (Internal Medicine) 2016. Available from: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/148_nephrology_int_med_2016.pdf

2. Berns JS, O’Neill WC. Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs. Clin J Am Soc Nephrol 2008; 3:941–947.

3. Berns JS: A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 2010; 5:490–496.

4. Sachdeva M, Ross D, Shah H. Renal Ultrasound, Dialysis Catheter Placement, and Kidney Biopsy Experience of US Nephrology Fellows. Am J Kidney Dis 2016; 68:187–192.

5. American Society of Diagnostic and Interventional Radiology: ASDIN. Available from: http://www.asdin.org/

6. Mendelssohn DC. Should nephrologists take a larger role in interventional nephrology, and should central line insertion remain a requirement of nephrology residency training? A debate. Can J Kidney Health Dis 2015; 2:10–12.

7. Jhaveri KD, et al. Why not nephrology? A survey of US internal medicine subspecialty fellows. Am J Kidney Dis 2013; 61:540–546.

8. Jain AK. Should temporary hemodialysis catheter insertion remain a requirement of nephrology residency training? Can J Kidney Health Dis 2015; 2:7.

9. Negoianu D, Berns JS. Should nephrology training programs continue to train fellows in the placement of temporary hemodialysis catheters? Semin Dial 2014; 27:245–47.