Helping Nephrologists Become Lifelong Learners

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Adapted from Ronald J. Falk, et al., Clin J Am Soc Nephrol 3: 1238-1241, 2008. doi: 10.2215/CJN.02980608, September 2008

Consider this: Approximately 80 percent of a nephrologist’s learning occurs after nine to 10 years of formal training. The implications of this statement for ASN are huge: The Society must provide high-quality learning opportunities for nephrologists throughout their careers, regardless of career focus, level of experience, or learning style.

ASN accomplishes this goal through several means: Renal Week and its offerings of short courses and clinical nephrology conferences, the annual Board Review Course and Update (BRCU), NephSAP, and through partnering with the American Board of Internal Medicine (ABIM) to help nephrologists complete maintenance of certification (MOC).

But first, how can it be that only 20 percent of a nephrologist’s learning occurs during those nine to 10 years of formal training?

Throughout their academic experience and professional careers, nephrologists learn within the context of an educational continuum for internal medicine that has four distinct phases. The first phase is the third-year internal medicine clerkship, which in U.S. medical schools lasts on average 10.5 weeks. Given the breadth and depth of internal medicine, it is not surprising that the exposure of medical students to career options in nephrology is limited.

During the second phase, internal medicine residency programs are required to include a “clinical experience in each of the subspecialties of internal medicine”; however, “it is not necessary that each resident be assigned to a dedicated rotation in every subspecialty” (1). It is during the third phase of learning, the two- to three-year nephrology fellowship, that an in-depth understanding of the broad discipline of the kidney in health and disease unfolds.

The fourth phase is the longest and least structured part of the continuum. Postgraduate education (PGE) or continuing medical education (CME), terms used interchangeably, refer to the educational experiences of a nephrologist during the rest of their 30- to 40-year careers. This is the phase during which nephrologists learn about 80 percent of what they will carry with them throughout their careers. ASN, then, has a responsibility to make every aspect of PGE/CME as high quality as possible for all nephrologists.

Renal Week

The centerpiece of the ASN educational program has always been—and always will be—its prestigious annual meeting, Renal Week. One- and two-day PGE courses take place during the first two days of Renal Week, offering 9.25 to 14.25 CME credits for a single course.

The Clinical Nephrology Conferences are held from 10 a.m. to noon and from 2 to 4 for three days of the conference, and official symposia are offered during breakfasts, lunches, and dinners.

A major long-term goal of ASN is to repackage the excellent programs offered at Renal Week to allow for additional opportunities for learning. Through its website, ASN can disseminate programs based on Renal Week to ASN members and others. Potential learning tools include webinars, audio files, and streaming video. As with sessions offered during Renal Week, these learning tools must provide nephrologists CME credits to maintain state licensure and MOC points to help complete recertification by ABIM.

Renal WeekEnds

Busy nephrologists, with ever-increasing demands on their time, may not have the time to attend Renal Week. Renal WeekEnds provide an opportunity for those who could not attend Renal Week to catch up on what they missed in a distilled version of the meeting that happens over one and a half days. Participants in one Renal WeekEnd earn 12 CME credits.

Renal WeekEnds also appeal to those who attended the annual meeting. Because Renal Week’s sessions occur simultaneously, participants simply cannot attend them all. Enter Renal WeekEnds, which offer a way for individuals to catch up on sessions they could not attend at Renal Week.

The time constraints of Renal WeekEnds will drive ASN to create enhanced opportunities for learning at these sessions in the near future. Moving into the digital era, for example, ASN will continue to refine the organization of Renal WeekEnds, which will increase the interaction among participants, speakers, and co-chairs. As with Renal Week, Renal WeekEnds will provide opportunities for learning through downloading digital files from the ASN website.

Board Review Course and Update

The Society’s BRCU provides participants a superb update in nephrology as well as preparing them for initial certification or MOC examinations by ABIM.

Moving forward, ASN is aware of the need to focus on those who attend BRCU for an update. The course’s faculty makes a point of separating “Pearls for the Boards” from the evolving and sometimes controversial “Updates.” ASN is increasing the quality of content testing material used during BRCU, in order to provide both updates and preparation for ABIM examinations. Likewise the answer key to the BRCU practice exam will be expanded to include a detailed discussion of the rationale supporting the correct answers.

As with other ASN educational materials, BRCU will begin to develop a presence on the Society’s website.

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ASN and Maintenance of Certification

Several organizations are responsible for evaluating the quality of nephrologists during the PGE/CME phase of their careers, including ABIM, the Accreditation Council for Continuing Medical Education (ACCME), and the Federation of State Medical Boards (FSMB). FSMB licenses physicians to practice in their respective states, districts, or territories in the United States. To remain licensed, physicians must pursue CME throughout their careers. ACCME accredits CME providers, such as ASN and most other specialty societies.

ABIM evaluates general internists after their residency training and nephrologists after their fellowship training. General internists and nephrologists must renew their certificates through ABIM’s MOC program every 10 years. To complete MOC, a nephrologist must maintain an unencumbered medical license through FSMB; demonstrate self-evaluation of medical knowledge; pass “a secure computer-based, cognitive examination” administered by ABIM; and measure aspects of his or her practice, reflect on these results, and consider how he or she can improve based on this feedback (2).

ASN partners with ABIM to help nephrologists complete two parts of MOC: self-evaluation of medical knowledge and self-evaluation of practice performance.

Nephrologists have largely relied on NephSAP to evaluate their medical knowledge. NephSAP combines challenging questions based on case vignettes and a detailed syllabus that reviews recent publications. Taken together, the vignettes and syllabi are intended to help nephrologists self-assess their strengths and weaknesses in nephrology.

During a two-year period, the editors of NephSAP address 12 distinct topics in nephrology. Eight of these issues, such as chronic kidney disease, are core aspects of nephrology, whereas four issues cover variable topics such as renal imaging. Audio versions of NephSAP launched on ASN’s website in October 2008 allow some nephrologists to offset their “windshield time” between dialysis centers and hospitals.

In addition to NephSAP, part 2 of MOC can also be achieved by attending the two-day recertification review course that is part of Renal Week. Advances in internal medicine and nephrology are reviewed using update modules developed by ABIM. Case vignettes followed by questions are reviewed by an expert panel.

To complete part 4 of MOC, nephrologists use ABIM’s Practice Improvement Modules (PIMs). According to ABIM, a PIM is a “web-based evaluation and improvement tool focused in a clinical area relevant to the physician’s practice, such as diabetes, hypertension, or hospital-based care.”

ABIM currently offers PIMs in seven areas, including chronic conditions, prevention, and communication. ASN has started to work with ABIM to develop PIMs in areas of greatest interest to nephrologists, such as chronic kidney disease and dialysis. Ideally, directors of nephrology fellowship training programs will also consider using nephrology-relevant PIMs as teaching and evaluation tools for fellows.

ASN is committed to helping ABIM develop PIMs and related tools for nephrologists, producing self-assessment materials for nephrologists, and providing nephrologists credit for CME through the Society’s educational activities. In addition, ASN will continue to ensure that the organizations responsible for evaluating the quality of PGE/CME think creatively about assessment tools that work in the real world for every nephrologist.

Challenges and Opportunities

The ASN educational enterprise currently includes synchronous (learners and teachers are in the same place at the same time) learning opportunities such as Renal Week, Renal WeekEnds, and BRCU. ASN is also now adding asynchronous (for example, web-based) learning to Renal Week, Renal WeekEnds and BRCU.

ASN is committed to developing as many ways as possible for helping nephrologists earn CME credits and MOC points. At the same time, the Society must develop a strategy for dealing with several challenges. The Society must produce educational material that is relevant for all types of nephrologists, such as those interested in acute kidney injury, dialysis, or transplantation. Each subspecialty within nephrology is well-represented by organizations that meet the needs of that constituency. So ASN’s educational offerings must appeal to general nephrologists and every subspecialist within nephrology as well as link the renal community from an educational perspective.

ASN must also address efforts to centralize, and possibly homogenize, the first three phases of the educational continuum (medical school, internal medicine residency, and nephrology fellowship). Today’s physicians-in-training must master the six core competencies required by the Accreditation Council for Graduate Medical Education (which accredits residency and fellowship programs) and the American Board of Medical Specialties. Four of these competencies (medical knowledge, patient care, professionalism, and interpersonal skills and communications) are familiar to previous generations of physicians. But competencies for systems-based practice and practice-based learning and improvement are relatively new.

The fourth phase of the educational continuum (PGE/CME) will offer the primary mode for ensuring the competence of nephrologists. ASN must balance the responsibility to help all nephrologists meet the expectations for CME and MOC throughout their careers with the need to appeal educationally to the myriad subspecialists within nephrology.

References

1. 

Accreditation Council for Graduate Medical Education: Internal Medicine Program Requirements. http://www.acgme.org/adWebsite/RRC_140/140_prIndex.asp.

2. 

American Board of Internal Medicine: Board Certification: A Path to Quality Care, Philadelphia, PA, American Board of Internal Medicine, 2007.