The ABIM Boards and Fellowship: The Past, Present, and Future

The past decade has been a challenging time for nephrology. The increasing demand for kidney care combined with recent match challenges calls for the strengthening of fellowship training. This translates into a need to evaluate nephrology training, with the American Board of Internal Medicine (ABIM) nephrology subspecialization certification traditionally an objective way to accomplish this. The pass rate for the board exam, however, has seen continued struggles, with the 80% pass rate in 2020 being an improvement from the year prior but still the lowest among medicine subspecialties. A recent Kidney News article hypothesizes that this decline is potentially due to a combination of factors. These factors include the mismatch between exam content by ABIM question writers and real-world clinical experience and insufficient preparation for the exam by the fellows and/or fellowship programs (1).

So what should programs do to prepare fellows for this high-stakes exam (Table 1)? The ABIM Nephrology Certification Examination blueprint serves as an outline for preparation for both individual fellows and the program core curriculum (2). The In-Training Exam (ITE) can then be used to gauge knowledge gaps, as it has shown to be an independent predictor of performance on the initial certification exam (3). Several tools are at our disposal to enhance education. A 2018 Renal Fellow Network survey showed that the Kidney Self-Assessment Program (KSAP), ASN Board Review Course & Update (BRCU), and Nephrology Self-Assessment Program (nephSAP) are the most popular resources utilized by fellows (4). Fellowship programs should also have protected board question-based sessions, core lecture series, and innovative tools (5) starting early in the first year, with particular emphasis on complex topics such as renal physiology and pathology. Various resources are available that simplify instruction and guide training. A recent article in Kidney News by Garcia and Reddy provides an excellent curated list of fellow-friendly resources, highlighting available courses, societies, annual meetings, and development opportunities (6).

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And what does the future hold for board preparation and fellowship? A 2016 national study of nephrology fellows highlighted a need for increased time on education in home dialysis modalities and renal pathology and physiology (7). The current emphasis on promoting and expanding home therapies necessitates that nephrology fellows receive adequate training in home dialysis modalities. It is thus concerning that a study of US nephrology fellows showed an overall perceived preparedness moderate for peritoneal dialysis and low for home hemodialysis (8). This emphasizes a critical need to increase education toward home dialysis modalities through lectures, conferences, and enhanced hands-on outpatient experience. The focus on expanding nephrology education should come with an awareness of the limited time fellows have for independent study, especially when on clinical service. Programs can consider restructuring rotations by incorporating physician extenders to lighten fellows' workload, especially for patients with whom fellows have ample learning opportunities (i.e., patients with end-stage kidney disease on hemodialysis). Finally, the landscape of nephrology is changing, with increased emphasis on onco-nephrology, business, health policy, interventional nephrology, glomerular disease, and critical care nephrology. Assessment of these areas on the ABIM Nephrology Board Exam will require future thoughts.

The changes of the past decade of nephrology fellowship training such as low board pass rate, decrease in procedural competency, and a workforce shortage unveil current areas in demand of improvement. The future of nephrology training should include the development and application of universal novel educational modalities in fellowship to strengthen training and increase interest among upcoming generations of learners.

Low board pass rate, decrease in procedural competency, and a workforce shortage [are] areas in demand of improvement.