The ASN Task Force on the Future of Nephrology: What Have We Been Hearing?

From people with kidney diseases

A predominant message from the group of people with kidney diseases was for fellowship programs to focus more on patient engagement and activation. They stressed that rehabilitation of people with kidney diseases is an essential component of care and deserves further emphasis during training. Recommendations included a greater focus on developing a holistic approach to patients and more attention on effective communications skills. They want our graduates to be more aware of individualizing their approach to patients and to understand that patient preferences often evolve over time. As one participant reminded the task force, “Kidney diseases are a diagnosis for life.” Areas in which people with kidney diseases would like to see better training include home therapies, care transitions (especially pediatric to adult), women's health, and preventive nephrology. When considering requirements in training related to procedures, they asked that we take into account the patient experience.

From practicing nephrologists

A listening session was held with practicing nephrologists where the consensus was that fellows should understand procedures, such as insertion of dialysis catheters and kidney biopsy, but they do not need to be trained to competency, as most practices no longer perform these procedures. This message was consistent with the 2021 ABIM survey of certified nephrologists, which indicated that 70.9% do not perform insertion of temporary dialysis vascular access, and 83.1% do not perform kidney biopsies (2). They did ask for a greater focus on point-of-care ultrasound (POCUS) and the interpretation of radiologic studies. There was consensus that graduating fellows should have a better understanding of the business aspects of a nephrology practice, including health economics and value-based care. The practicing nephrologists emphasized that there are many income-generating opportunities for practices that contribute to a nephrologist's compensation, which may make the specialty more attractive as a career. Other recommendations included more training in the areas of home therapies, outpatient nephrology (including longitudinal dialysis care), team-based care, assessment of dialysis access, population health, communication skills (especially related to the electronic health record), urology, and conservative management of kidney failure.

From nephrology fellows

The task force met with current and newly graduated nephrology fellows whose perspective was to keep procedures as a requirement for training, fearing that we were “giving away procedures when other specialties were not.” They felt it was important for nephrologists to perform procedures because it was best for patients and avoided fragmenting care, and procedures were one way to attract future applicants. They urged the task force to “protect the specialty.” Fellows stated that there should be more training in home dialysis therapies and POCUS, with recognition that most internal medicine residents are competent in POCUS. Training programs should increase opportunities to learn more specialized areas of nephrology by making more effective use of the second year of training, they added. The fellows also recommended a greater focus on mentorship, reducing workload, and improving fellow well-being, stressing they need time to learn.

From fellowship training program directors

Nephrology fellowship training program directors offered recommendations through several retreats, a survey conducted by the ASN Workforce and Training Committee, and a listening session that focused on smaller training programs. Although no consensus was reached on procedural requirements for graduation, a majority emphasized the importance of providing opportunities to train in procedures. They did feel more training was needed in the areas of home therapies and POCUS, however. Other points made to the task force during the listening session were centered on the challenges of filling fellowship positions, the need for greater attention on fellows who enter nephrology as a “second choice,” and the concern that training resources were often limited in smaller fellowship programs.

These listening sessions were in addition to input provided by individual nephrologists, ASN committees, the ACGME and ABIM advisors to the task force, and other specialty medical societies (including cardiology and hematology). In addition, to support the data-driven approach that the task force has been taking, we had the opportunity to review surveys by ABIM of certified nephrologists, nephrology fellowship training program directors about procedures by ASN, and ASN regarding other workforce-related issues. Additional input is planned from nephrology division directors and the chief medical officers of dialysis organizations, as well as from other kidney organizations.

The task force greatly appreciates the thoughtful opinions and generous time provided by these various stakeholders. Clearly, our community is engaged and interested in this important work. The next step for the task force is to synthesize this input into specific strategic recommendations about how to best train fellows for the future of nephrology. There is still time to provide your perspective. To share your ideas, please email Melissa West, ASN's Senior Director for Strategic Relations and Patient Engagement, at mwest@asn-online.org.