Nephrology Training Program Directors Join Forces with ASN Training Program Director Executive Committee

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U.S. nephrology training program directors (TPDs) are increasingly joining forces to meet many of today’s current challenges. These efforts are spearheaded by the American Society of Nephrology’s (ASN) TPD executive committee. The committee consists of members elected by the TPD community to serve three-year terms, and is led by the ASN Education Director for Nephrology Fellowships.

TPDs and the TPD executive committee have been involved in several important issues of late, including participation in the national residency matching program and establishment of the in-training examination and geriatric nephrology curriculum.

National Residency Matching Program

The first nephrology match took place in 2008 for nephrology applicants starting their nephrology training in July 2009. The decision to join the Match was made possible by extensive education of nephrology TPDs and other faculty about the match, followed by careful attention to any problems during the match process.

Approximately 90 percent of training programs and 90 percent of positions were filled by applicants through the match process. This year, about 91 percent of positions and applicants are anticipated to participate in the match. Although the match process has entailed most programs interviewing more applicants, in general, the match has been met with enthusiasm by both programs and applicants.

In-training examination

In response to the perceived need by TPDs for a standardized instrument to assist in the formative evaluation of trainees, and to help meet Residency Review Committee-Internal Medicine (RRC-IM) requirements, the ASN TPDs, under the leadership of Mark Rosenberg initially and then Mitch Rosner, developed an in-training examination in conjunction with the National Board of Medical Examiners (NBME). The examination was written by ASN volunteers who were trained by the board in writing questions.

The first version of the test was taken in April 2009. As of this writing, 693 fellows had registered to take the test, representing more than 80 percent of nephrology fellows. According to the NBME, this is the highest percentage of fellow participation in an in-training examination given for the first time by any internal medicine subspecialty.

The TPDs will be analyzing results of the first examination and making appropriate modifications for future tests. Finally, it should be emphasized that the in-training examination is intended as a tool only for internal use by TPDs to identify areas presenting challenges to fellows or to their entire training program.

Accreditation Council for Graduate Medical Education nephrology program requirements

The RRC-IM is in the process of revising the program requirements for nephrology training and has solicited input from all TPDs. The TPD executive committee and the nephrology TPD community have met with members of the RRC-IM and have submitted recommendations to the RRC-IM for changes in the current program requirements. These recommendations have undergone numerous revisions by the TPDs in response to reviews by the RRC-IM and are currently in the final phases of RRC-IM evaluation. The new regulations will be reviewed by the American Council of Graduate Medical Education (ACGME) Board of Directors in September 2009, and, if approved, will become effective in July 2010.

A variety of changes in the regulations are being proposed. Details on such changes can be obtained by contacting any TPD. In general, the changes are intended to give programs more latitude in their approach to training nephrology fellows, with the caveat that programs are being increasingly required to document and diversify their teaching and evaluation processes in accordance with the ACGME core competencies.

Geriatric nephrology curriculum

The ASN received a T. Franklin Williams grant through the Association of Specialty Professors to develop a curriculum in geriatric nephrology. Dimitrios Oreopoulos assumed leadership of this group and recruited a group of outstanding geriatricians and nephrologists to write the curriculum. Jocelyn Wiggins has joined as a co-leader of the group. A curriculum consisting of 35 modules of about five pages each has been developed and will be placed on the ASN website in the near future. It will be freely available to everyone.

Increased focus on education during Renal Week

The TPD executive committee, working together with the ASN Council and the Renal Week program committee, has created a new education “area” for which individuals may submit abstracts to ASN Renal Week. This area encompasses education of fellows, faculty, or program directors. The first such abstracts were presented at ASN Renal Week 2008 and were met with much enthusiasm by program directors and other teachers. We strongly encourage individuals to consider submission of abstracts dealing with educational topics for the upcoming 2009 Renal Week.

TPD retreats

The first nephrology TPD retreat was held in May 2007. Key issues discussed at this retreat were the match, the in-training examination, and the pending changes to the ACGME-RRC-IM requirements. At the second nephrology TPD retreat, held in May 2009, six small groups each addressed an area of major relevance to training programs and fellows:

  • Interest in nephrology as a career. While international medical graduates constitute a valued and important contingent of trainees, there is relatively low interest in nephrology as a career among U.S. medical graduates. The goals of this group are to identify target groups (likely medical students and residents), to identify methods to attract their interest (e.g., mentoring, conferences, research, and clinical exposure), and to increase the effectiveness of recruiting through training mentors and professional faculty development.

  • Evaluation tools. The goals are to identify, create, deliver, and validate formative and summative tools to assist core competency compliance. Programs are free to use whatever tools they wish; however, the goal is to provide them with a variety of options so each program does not have to develop its own tools.

  • Peritoneal dialysis training. A number of training programs struggle to achieve adequate peritoneal dialysis (PD) training, in large part due to the small numbers of patients receiving PD. A PD working group, whose primary goal is initially to develop a PD curriculum, has been formed. This group will work closely with TPDs to identify barriers to adequate PD training and to develop methods for fellows to achieve competency in PD. Joni Hansson has taken a leadership role in this group.

  • Curriculum development. This group will focus on areas of the nephrology training curricula that are in special need of development. Such areas include ethical aspects of renal care and transition of patients from pediatric to adult nephrology care. The groups will identify curricula needing special development and then work to create subgroups to define and develop the curricula content.

  • Teaching toolkit development. This group will develop teaching tools that programs can use to help implement curricular goals and objectives. They will identify areas in need of tool development, identify methods to effectively teach these areas, and help align the teaching methods with core competencies. Examples include the development of standardized patients and simulators.

  • New TPD training course and work group. This group is in the process of developing a course designed to help train new TPDs. They will work to develop ways to provide TPDs with ongoing education about all aspects of being a TPD.

These activities of the TPD executive committee and nephrology TPDs reflect the collective efforts of nephrology educators. It is heartening to witness nephrology TPDs emerge as one of the most proactive groups of TPDs among internal medicine subspecialties.

It is clear that nephrology TPDs are individuals dedicated to helping recruit high quality trainees, to making their educational experience as valuable as possible, and to making the process of their education (including obtaining ACGME accreditation) as easy as possible. The extensive duties required of a TPD are not always recognized nor adequately compensated. It is hoped that with increasing visibility and recognition of their critically important role, nephrology TPDs will be given the full modicum of credit and support that is essential to their role in training future generations of nephrologists.

Donald Kohan, MD, PhD, is director of the nephrology training program and assistant dean of graduate medical education at the University of Utah Health Sciences Center in Salt Lake City.