Nephrology Fellowship Recommendations Emphasize Competency-Based, Individualized Training

Competency-based

The fellowship-specific recommendations call for nephrology to adopt a competency-based training model like that of the American College of Cardiology’s Core Cardiology Training Symposium.

The first recommendation focuses on establishing three levels of competency. The first level of competency would focus on core skills, values, attitudes, and knowledge that every nephrologist needs, similar to the first 12 months of current fellowship training. The second level would focus on experience with advanced procedures and patient care. Fellows could achieve the first two competency levels in a standard 2-year fellowship program. More individualized training to meet fellows’ individual career goals could begin in the second year and potentially stretch into an optional third year. For example, a third-year program may focus on kidney transplant or nephrology procedures, Rosenberg explained.

The second recommendation calls for fellowship programs to create more individualized pathways to meet individual career goals. Programs could offer specialized training in subspecialties, such as kidney disease prevention, hypertension management, onconephrology, or palliative care. Programs might also include training in business or leadership, medical education, or research. “This recommendation will provide an opportunity for fellowship programs to distinguish themselves and to market some of the specialized areas of expertise,” Rosenberg said.

The third recommendation calls for a greater emphasis on personalized care in alignment with the goals of the Advancing American Kidney Health initiative, which focuses on earlier diagnosis and prevention, prioritizing transplants, and giving patients treatment options, such as home dialysis.

The fourth and most controversial recommendation, according to Rosenberg, addresses expectations for fellows’ procedural competency. The proposal calls for fellows to be knowledgeable about the procedures, their indications, and potential complications and to be able to advise patients about their options. However, it does not require competency in the procedures themselves. Programs are encouraged to provide opportunities in-house or offer external options for fellows who wish to pursue training in vascular access placement or kidney biopsies.

Rosenberg said the recommendation better reflects the realities of current nephrology practice in which most nephrologists either never perform these procedures or rarely do. Task force member Benjamin Humphreys, MD, PhD, the Joseph Friedman Professor of Renal Diseases in Medicine and chief of the Division of Nephrology at Washington University School of Medicine in St. Louis, MO, said that he initially was against the change. However, he was swayed by learning that many program directors felt forced into an ethical conundrum of certifying fellows as procedurally competent when many fellows do not feel competent. “The train has left the station already in terms of the reality of our workforce,” Humphreys said.

Patient safety is another primary consideration, said task force member Suneel Udani, MD, consulting physician at Nephrology Associates of Northern Illinois and Indiana (NANI) Research, in Oak Brook, IL, who said the task force wanted to ensure that every fellow certified to do these procedures is doing them as safely as possible.

The fifth recommendation is to identify and close gaps in nephrology training. Rosenberg said this might include training in patient-centered care and patient engagement, addressing health disparities, regulatory aspects of kidney care, or the financial operations of a nephrology practice. Task force member Sharon Anderson, MD, professor and dean emeritus, Division of Nephrology & Hypertension, at Oregon Health & Science University in Portland, also noted the gaps in training for home dialysis and transplant care and recommended more systematic analysis of training gaps in the field. “This is important for nephrology to do on a regular basis, where we take a deep look at ourselves at how we’re practicing,” Anderson said.

Wellness and justice

The second set of recommendations requires collaboration between nephrologists and the broader health care system. These recommendations include improving fellow wellness; prioritizing diversity, equity, inclusion, and health care justice; ensuring equal opportunities for all nephrologists; fostering interprofessional and interdisciplinary practice; and promoting lifelong learning. “Promoting the well-being of fellows is a patient-safety issue,” Rosenberg said. “It’s a quality-of-care issue.”

Improving the wellness of nephrology fellows may also help improve recruitment to the field when there is intense competition, said task force member Robert Hoover, Jr., MD, chief of the Section of Nephrology and Hypertension at Tulane University in New Orleans, LA. He said his program has successfully boosted recruitment by emphasizing measures to improve fellow wellness. For example, the program created a night float service to prevent fellows from having to respond to a call overnight and then work in the morning. Hoover’s program also gives fellows an extra half day off each month. He emphasized the need for a program to protect fellows’ time to learn and faculty’s time to teach.

The task force’s report emphasizes the urgent need to address the disproportionate burden of kidney diseases on people who are Black, Hispanic, Native American, Native Hawaiian or other Pacific Islanders, or Asian American. “We as a community have to have a laser focus on health equity,” said task force member Janis Orlowski, MD, a nephrologist and chief health care officer at the Association of American Medical Colleges in Washington, DC.

The recommendations also emphasize the need for equal opportunities for nephrologists who graduated from an allopathic or osteopathic training program or who are international medical graduates. For example, the task force’s report notes that one-half of nephrologists and 70% of nephrology fellows are international medical graduates. “More and more of our fellows are DOs [doctor of osteopathic medicine] and international medical graduates,” Rosenberg said. The report emphasizes the need to support the success of the joint accreditation program created in June by ACGME, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine (2) and address barriers associated with the US visa program.

ASN is collecting feedback from members about the recommendations and will work with program directors at fellowship programs to help them get the necessary time, resources, and support to implement the changes. “We are here to support you,” said Melissa West, senior director for strategic relations and patient engagement with the ASN Alliance for Kidney Health.