Physician Education in Care of Peritoneal Dialysis Patients During Fellowship and Beyond: Opportunities and Challenges

The use of peritoneal dialysis for treatment of ESRD in the United States has remained low (approximately 7 percent) despite an expanding number of patients reaching ESRD. It has been suggested that limited fellowship training in peritoneal dialysis may be one of the factors contributing to this decline, because this can result in provider inexperience and bias against peritoneal dialysis as a modality for treating ESRD.

The Accreditation Council for Graduate Medical Education program requirements for graduate medical education in nephrology state: “Fellows must have formal instruction, specialized clinical experience and demonstrate competence in dialysis,” which includes peritoneal dialysis. Over the past decade, several surveys have examined dialysis training from the perspective of program directors and graduates. In general, it is thought that fellowship training in peritoneal dialysis is inadequate and needs to be improved. Less time is spent with didactic teaching and direct care of peritoneal dialysis patients in comparison with hemodialysis. In fact, fellows in most training programs follow up five or fewer peritoneal dialysis patients in the ambulatory setting during their fellowship.

To address the concerns of fellowship education in peritoneal dialysis, several educational initiatives have been developed (Table 1). Several educational courses are now available for peritoneal dialysis. The Peritoneal Dialysis University, developed in 1999 and now known as Home Dialysis University, is a 2.5-day course offered four to five times a year. Many training programs use these courses to supplement their curriculum for their fellows.

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Unfortunately, not all fellows (or nephrologists wishing to expand their knowledge of peritoneal dialysis) can attend one of these conferences. This led to a collaborative effort of the training program directors, the ASN Dialysis Advisory Group and the North American Chapter (NAC) of the International Society of Peritoneal Dialysis (ISPD) to develop a comprehensive curriculum in peritoneal dialysis that is available online for all to use. This curriculum contains 20 presentations with references and questions to test learning. It includes peritoneal dialysis basics, management and complications of peritoneal dialysis, educational resources, and special topics. The ASN Dialysis Advisory Group has developed the ASN Virtual Mentor Dialysis Curriculum, which is also freely accessible online and covers all aspects of dialysis, including peritoneal dialysis. These educational resources offer wonderful opportunities for fellows, nephrologists, and other health care providers to learn all aspects of peritoneal dialysis.

Our greatest educational challenge is ensuring an adequate patient care experience in peritoneal dialysis. Many fellowship programs have limited exposure to the care of patients receiving peritoneal dialysis, either because of a small number of peritoneal dialysis patients at that institution or because of scheduling conflicts with other fellowship requirements. Fellowship programs must ensure that time is built into the fellow’s schedule for an ambulatory peritoneal dialysis experience, and they should consider using local offsite clinics within or outside the institution.

Future educational initiatives should focus on novel programs to provide a meaningful experience with ambulatory peritoneal dialysis so that fellows can learn how to treat patients receiving peritoneal dialysis and understand how to develop and structure a peritoneal dialysis program. For example, training sites could be developed in large successful peritoneal dialysis units across the country that have a standardized experiential curriculum for the care of peritoneal dialysis patients. Programs with limited peritoneal dialysis patients could send their fellows to such a program for 1 week. A precedent for such a program exists through initiatives in Toronto and New Haven. Another example is faculty development (“train the trainer”) in peritoneal dialysis, so that faculty will embrace and grow peritoneal dialysis programs at their institutions. This could be accomplished by developing a resource/mentoring programs for nephrologists interested in expanding peritoneal dialysis in their practices. All these initiatives, it is hoped, will enhance the educational experience that fellows will have in caring for patients receiving peritoneal dialysis.

Fellowship training in peritoneal dialysis is quite variable and needs to be improved. This has led to the development of multiple educational resources in the care of patients receiving peritoneal dialysis. However, in the future we need to focus on how to enhance and ensure a direct patient care experience in peritoneal dialysis. Knowledge and experience will result in the growth of peritoneal dialysis as a modality for ESRD and also will improve fellowship training and patient outcomes.

Notes

[1] Joni H. Hansson, MD, is nephrology fellowship program director at the Hospital of Saint Raphael and assistant clinical professor at Yale University School of Medicine in New Haven, CT.

August 2012 (Vol. 4, Number 8)