Medical knowledge and patient complexity are rapidly growing, particularly in nephrology, one of the most complex medical sub-specialties (1). This complexity allows for diversity in practice as nephrologists often develop niche areas of expertise including glomerular diseases, home dialysis, and transplantation, among others. Glomerular diseases are a particularly stimulating aspect of nephrology. The multi-systemic nature of these diseases tends to elicit interest from individuals with a strong intellectual curiosity. The ability to effectively treat glomerular diseases, in some cases warding off kidney failure, can make it an extremely rewarding process. In addition, the chronic nature of these diseases leads to a long-term patient-doctor relationship with a strong rapport. Due to the scarcity of large, high-quality studies, physicians are often required to individualize management through involvement of the patient and shared decision-making. Close collaboration with a multidisciplinary medical team (renal pathology, rheumatology, and pulmonology, to name a few) is inherent to the practice, making it both stimulating and diverse. Finally, there are many opportunities for research endeavors and the potential to make a distinct impact with practice-changing knowledge.
The knowledge a nephrology fellow must acquire within a 2-year period is tremendous, making it challenging to ensure competency in areas such as glomerulonephritis (GN) due to rarity and inconsistent exposure, unless pursuing a yearlong GN fellowship. Participation in longitudinal GN clinics may remedy this by ensuring regular exposure and patient follow-up. In addition to this, an emphasis on nephropathology teaching is essential given its integral role in diagnosing and understanding glomerular diseases. Both nephrology trainees and program directors acknowledge the importance of nephropathology education (2, 3). Regular renal biopsy rounds with nephropathologists, or even elective nephropathology rotations, are valuable teaching resources for trainees. Unfortunately, not all training programs have nephropathologists, and biopsies may be sent to other institutions, limiting learning opportunities (2). In such cases, collaboration with centers with nephropathology services would be beneficial by, for example, providing virtual lectures or biopsy reviews. There are also many GN educational sessions at the international, national, and regional levels that should be promoted by program directors. The Glomerular Disease Study & Trial Consortium (Glom-Con) offers GN-focused virtual seminars, conferences, and teaching series dedicated to trainees, allowing people from all over the globe to learn from world leaders in the field. Every year at Kidney Week, the American Society of Nephrology offers a comprehensive, multiday glomerular diseases update course. On a regional level, the Glomerular Disease Collaborative Network Annual Conference is offered to trainees from programs in the southeast United States. Program directors should promote these valuable educational resources to their trainees, particularly those who have an interest in the field.
Despite the opportunities available for advancing knowledge in GN outside of a fellowship, nephrology trainees who aspire to achieve proficiency and a niche area of practice in glomerular diseases should consider pursuing 1-2 years of a focused GN fellowship with qualified mentors. Extensive clinical exposure, beyond what can be achieved during 2 years of general nephrology training, is often required to develop expertise prior to independent practice given the rarity of glomerular diseases. GN fellowships allow fellows to gain clinical experience and expose them to the subtleties of managing patients with glomerular diseases and of dealing with immunosuppression. Furthermore, immersing oneself in a specific area for a dedicated period allows one to gain a deep understanding of the scientific literature—how to interpret it and how to apply it to clinical care. GN fellowship training may also provide research experience, clinical or basic science, and the ability to create lifelong collaborative networks. This is an important stepping stone for a career in academic medicine.
Setting up a successful GN practice may be challenging, and a GN fellowship is a great way to appreciate the organizational aspects of setting up a practice. Indeed, many factors need to be taken into consideration prior to establishing a GN clinic, such as reimbursement and patient sharing with other members in the practice group. This may start as a half-day clinic where general nephrologists direct their patients with glomerular diseases. Additionally, providing a multidisciplinary clinic with rheumatology, dermatology, or pulmonology requires proper planning but addresses the multisystemic nature of GN and may improve patient care. Setting up infusion centers for administration of therapies or even a biopsy suite could help make the clinic financially attractive and convenient for patients. With an associated infusion center, the opportunity for research, including clinical trials, also becomes more feasible. Finally, and most important, delivering multidisciplinary care, including allied health professionals such as nurses, dieticians, pharmacists, and social workers, allows one to provide comprehensive patient care and helps facilitate access to medications.
This can all seem like a daunting task but working during a GN fellowship in an environment that can then be used as a model of care is an invaluable opportunity. Therefore, those who strive for a career devoted to glomerular diseases should be encouraged to pursue a GN fellowship, as this will put them on the path to success and allow them to approach independent practice with confidence.
Tonelli M, et al. Comparison of the complexity of patients seen by different medical subspecialists in a universal health care system. JAMA Netw Open 2018; 1:e184852. doi: 10.1001/jamanetworkopen.2018.4852
Mechery V, et al. Nephropathology education during nephrology fellowship training in the United States. Kidney Int Rep 2017; 3:236–241. doi: 10.1016/j.ekir.2017.11.01
Rope RW, et al. Education in nephrology fellowship: A survey-based needs assessment. J Am Soc Nephrol 2017; 28:1983–1990. doi: 10.1681/ASN.2016101061