Some nephrology fellowship programs are not providing all fellows the required training in several procedures, ASN and the American Board of Internal Medicine (ABIM) charge in a letter to the programs’ accrediting agency.
The two organizations sent a formal letter to the Accreditation Council for Graduate Medical Education (ACGME) expressing concern that some accredited nephrology training programs provide little or no experience in performing kidney biopsies, placing temporary vascular access for hemodialysis, and placing dialysis catheters for continuous renal replacement therapy.
“Despite the debates in recent years about the need to retain requirements for competency in biopsies and temporary hemodialysis catheter placement, they are current requirements,” according to the May 16, 2019, letter addressed to Thomas J. Nasca, MD, president and CEO of ACGME. The letter was signed by ASN President Mark E. Rosenberg, MD, FASN, and Jeffrey S. Berns, MD, FASN, chair of the ABIM Nephrology Board. “Both published literature during the last decade as well as substantial anecdotal evidence have made it abundantly clear that some nephrology fellowship programs accredited by the ACGME provide little or no experience” with the procedures.
The concern has been a topic of discussion at ASN Nephrology Training Program Retreats and is widely acknowledged within the nephrology training community, Drs. Rosenberg and Berns state.
ASN Councilor David H. Ellison, MD, FASN, who serves as liaison to the ASN Workforce and Training Committee, said he expects the next step will be for ASN, ABIM, and ACGME to meet and begin a dialog on the issues.
ACGME to respond
“The ACGME has received the letter and is taking the questions seriously,” Susan White, director of external communications at ACGME said in an email to Kidney News. “The ACGME will provide the recommendations to the appropriate specialty review committee—in this case the Internal Medicine Review Committee, which is made up of leading educators in the specialty, as well as a public member and resident—to review as we do with all recommendations. [The committee] will review the information provided and discuss the recommendations per our process. The ACGME will respond directly to the organizations that sent us the letter.”
Some fellows lack procedural skills
Surveys have found that nationwide about 25% of graduating fellows have not achieved competence to perform dialysis catheter placement or kidney biopsies (or both) without supervision, despite being ACGME program requirements. “Some programs provide no hands-on training in one or both of these procedures or little to no experience with taking care of patients utilizing home dialysis (either home hemodialysis or peritoneal dialysis),” the letter states.
A recent survey of nephrology program directors published in CJASN found that “51% indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications.”
A similar survey published in the Journal of Vascular Access found that only 55% of program directors believe that competence in non-tunneled temporary hemodialysis catheter insertion should be a requirement.
Core competencies, says ASN
Despite these reservations by program directors, “the ASN Council just voted specifically to endorse the view that biopsies and lines are things that nephrology programs should provide training in because they are so essential to the practice of nephrology,” Ellison said.
He said he could envision a system in which fellows were offered different pathways, in which some fellows would receive hands-on training in performing biopsies and in another track the fellow would simply master the indications for and complications of biopsy, leading to two different certifications. But that idea would provide flexibility for the individual, but not the program. “ACGME should make sure that programs are only [accredited] if they can train people in all the things that are required to be certified. The programs should be able to demonstrate that they provide home dialysis training, biopsy training, and line training,” Ellison said.
Berns, chair of the ABIM nephrology board, said that when he interviews applicants for his fellowship program, they confirm that they have visited programs where they have been told they won’t get any experience doing kidney biopsies. Berns said this is a difficult situation for applicants, who can’t know enough about the field to realize that by choosing the wrong program they could be limiting their future employment options.
“They can decide after the conclusion of training whether they ever want to do them again, but it is hard to expect somebody who is coming into fellowship training to make an intelligent decision about whether or not they want to develop these skills,” Berns said. An applicant should be able to go to every single training program in the country when they are applying for fellowships and know that they are going to get training across the entire breadth and scope of the field. That is not the case right now.”
Distinction between lines and biopsies?
Rob Rope, MD, associate program director for the nephrology training program at Oregon Health and Science University, said he is “agnostic” about the need for training programs to cover all these procedures thoroughly. He sees a difference between the needs for competency in placing lines and performing biopsies.
When it comes to placing a temporary dialysis catheter, the primary decision a nephrologist makes is whether the patient needs dialysis. “If that decision is made, then a dialysis catheter has to be placed, and it doesn’t matter to me who does it. It is whoever is qualified,” he said. “Given the way that nephrology practice has gone, a lot of people in private practice will never place a nephrology catheter again. And therefore, in some ways we are spending time training people for something that doesn’t give them a lot of career benefit.
“My feeling is there is more variation with who does biopsies, so based on practice patterns, it makes more sense to [be trained in] that procedure than the dialysis catheter. Generally, kidney biopsies are done on patients who are going to be our long-term patients, and there is a risk/reward element,” he said. “It is helpful that the person doing the procedure knows how important the biopsy is [in terms of] how likely it is that the results will change the management of the patient.”
Clinicians may be more or less aggressive depending on how important it is to find what they may be looking for, perhaps making an extra pass when needed, Rope said.
Data needed
The CJASN and Journal of Vascular Access studies surveyed the graduates of a single nephrology training program, and found that in their current practices, 58% place non-tunneled temporary hemodialysis catheters and 35% perform biopsies. But those numbers are from the Walter Reed National Military Medical Center so may not be generalizable.
In the surveys of training program directors, the most common barriers cited to fellows achieving competency in biopsies were time (45%), logistics (45%), a belief that graduates were unlikely to perform biopsies (41%), and faculty unwillingness to supervise (30%). The most important barriers to achieving competence in installing catheters were “busyness of the service” (36%) and “disinterest” (21%).
Regarding that “unwillingness to supervise,” Rope noted that if nephrologists are no longer performing a procedure, it is not surprising they would experience difficulty teaching the next generation.
ASN and ABIM want to work with ACGME because it is “the only organization that can . . . make sure programs and program directors comply with the requirements and expectations of training . . . [and] close a training program, downsize a training program, [or] give citations to training programs,” Berns said.
The letter to ACGME notes “there are serious professionalism concerns stemming from false attestation of program directors to competencies that are not achieved, tacit acceptance of this inaccuracy by fellows knowing that their program directors are reporting dishonestly, and fellowship programs that continue to accept new fellows for training knowing that these fellows will not receive required training as well as procedural experiences and competencies.”
“We think this is a serious issue, and it is time to address it in a serious way,” Ellison said. The goal is not to shut programs down, but to have programs producing the kind of nephrologists we think should be in practice,” Ellison said.
