Implementing 10 Recommendations to Help Forge the Future of Nephrology

Ibrahim Tod Tod Ibrahim, MLA, is Executive Vice President, American Society of Nephrology, Washington, DC. You can reach him at

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Nearly 50 years to the day after former President Richard M. Nixon signed the Social Security Amendments of 1972 into law (Public Law 92-603) establishing the Medicare End-Stage Renal Disease Program, the ASN Task Force on the Future of Nephrology issued its final report (1, 2). Due to deadlines from external regulators, the task force had less than 1 year to reach consensus and issue recommendations to help shape the specialty's future.

Given the task force's tight timeframe, the final report focuses on the “why” and the “what” of its 10 recommendations, not the “how.” This editorial outlines how ASN will work with the kidney community and other stakeholders to implement these recommendations.

Responding to requests from the American Board of Internal Medicine (ABIM) and the Accreditation Council for Graduate Medical Education (ACGME) about training requirements in nephrology, ASN established the Task Force on the Future of Nephrology in April 2022. ACGME accredits sponsoring institutions as well as participating residency and fellowship training programs, while ABIM (one of the American Board of Medical Specialties’ 24 specialty boards) certifies and recertifies individuals (general internists, hospitalists, and internal medicine subspecialists, including nephrologists).

To receive Medicare funding for medical education, an institution's residency or fellowship programs must be accredited by ACGME. Through Medicare, the federal government pays more than $16 billion annually for medical education (3). Starting July 1, 2023, ACGME will also become responsible for overseeing J-1 visa holders in non-accredited fellowship programs (such as transplant nephrology); because these programs are not accredited by ACGME, they are not eligible for federal educational funding through Medicare (4).

In January 2022, ACGME initiated its 10-year review of fellowship program requirements for the 17 internal medicine subspecialties, including nephrology. As a part of this process, ACGME requested ASN's input on nephrology fellowship training program requirements. At the same time, ABIM requested ASN's perspective on whether current procedural requirements for certification in nephrology should be reduced, maintained, or expanded. For years, ABIM, nephrology fellowship training program directors, nephrology fellows, and other stakeholders have debated this topic (57).

ASN sent ACGME and ABIM a joint letter in March 2022 requesting 8 months to establish a task force, engage the kidney community to consider all aspects of the future of nephrology, and determine how to best prepare nephrology fellows for future opportunities and challenges (8). After an intense 8-month process that included weekly videoconferences, discussions with advisors from ABIM and ACGME, constituency-specific interactions with the kidney community and other stakeholders, and an analysis of available data, the task force issued an interim report in September 2022. Based on feedback on the interim report from ASN members, other organizations—including the American Society of Transplantation, National Kidney Foundation, and Renal Physicians Association (RPA)—and key stakeholders, the task force revised the recommendations and issued its final report.

In its final report, which has been submitted for peer-reviewed publication, the task force makes 10 recommendations to help forge the future of nephrology (Table 1). To begin to implement these recommendations, ASN is pursuing four steps.

Table 1

10 Recommendations to help forge the future of nephrology

Table 1

Revise expectations for procedural training

During its reorganization in the 2000s, ABIM established 14 specialty advisory boards and committees “responsible for the broad definition of the discipline across Certification and Maintenance of Certification (MOC)” (or recertification) (9). Chaired by Rudolph A. Rodriguez, MD, ABIM's Nephrology Board is expected to deliberate task force Recommendation 4 to “reconsider expectations for training in procedures” this spring.

According to the task force, “All fellows must have the knowledge, skills, values, and attitudes to make decisions about the indications for both performance and complications of placement of temporary vascular access for hemodialysis and percutaneous biopsy of both autologous and transplanted kidneys.” To accomplish this goal, ASN has requested that ABIM and ACGME remove requirements for training in the placement of temporary vascular access for hemodialysis and percutaneous kidney biopsy. While some nephrology fellowship programs may still decide to provide training to competence in these procedures, the task force asserts that such training should not be required, although all fellows should be afforded an opportunity to train in these procedures if interested.

Chaired by Robert S. Hoover, Jr., MD, FASN, the ASN Workforce and Training Committee is responsible for working with ABIM and ACGME to try to make this change and for supporting nephrology fellowship training programs implementing any new policies in this arena. If the ABIM Nephrology Board agrees to “reconsider expectations for training in procedures” this spring, Stephen M. Sozio, MD, MS, FASN, who serves as the committee's co-vice chair, will lead members of the committee in identifying resources, tools, and talking points to support the 150 ACGME-accredited nephrology training programs’ transition to the new requirements (10).

Respond to ACGME's proposed changes to the next iteration of the fellowship training program requirements in nephrology

Currently, ACGME's Review Committee for Internal Medicine (RC-IM) is sharing proposed changes to the next iteration of fellowship training program requirements for several of the internal medicine subspecialties, such as cardiology. The ASN Workforce and Training Committee will identify which of these suggested changes could appear in forthcoming nephrology program requirements later this spring.

Led by Ursula C. Brewster, MD, who serves as the committee's co-vice chair, ASN will also begin to evaluate existing nephrology fellowship training program requirements against the task force's recommendations to identify opportunities to strengthen or change current requirements. For example, ASN should advocate that the program requirements “emphasize personalized care” (Recommendation 3); “promote the well-being of nephrology fellows” (Recommendation 6); “prioritize diversity, equity, inclusion, and health care justice” (Recommendation 7); and “inspire lifelong learning” (Recommendation 10).

In the coming months, ACGME's RC-IM will propose changes to fellowship training program requirements for the remaining internal medicine subspecialties, including nephrology. Besides providing a thorough response to these proposed program requirements, ASN will identify opportunities to support ACGME-accredited nephrology fellowship training programs with the anticipated changes. The new requirements are expected to go into effect no sooner than July 1, 2024.

Build a framework to support competency-based education in nephrology

Accomplishing three of the task force's first five recommendations will require considerable alignment, coordination, and commitment across ASN:

  • Enhance competency-based nephrology education (Recommendation 1). “Nephrology must enhance its approach to competency-based education by defining and standardizing three levels of competency across nephrology fellowship training programs.”

  • Establish individualized pathways to meet career goals (Recommendation 2). “Nephrology must establish individualized pathways to provide opportunities for fellows to explore advanced specialized care and other career goals in more depth.”

  • Close gaps in current nephrology training (Recommendation 5). “Nephrology must emphasize personalized care to optimize kidney health, including early intervention to slow CKD [chronic kidney disease] progression and increase patient choice regarding transplantation, dialysis, and conservative care.”

To accomplish these goals, ASN plans to establish an oversight task force that includes members from the ASN Workforce and Training Committee and the ASN Continuous Professional Development Committee, which is chaired by Karin A. True, MD, FASN. According to the task force, competency-based education in nephrology will consist of three levels:

  1. Level I includes the expected knowledge, skills, values, and attitudes of every graduating nephrology fellow. In all likelihood, this training would occur during the first 12 months of a 2-year nephrology fellowship.

  2. Level II includes training beyond general nephrology that provides fellows with opportunities to perform advanced procedures or clinical care. This training would likely occur as an elective during the second 12 months of a nephrology fellowship.

  3. Level III includes a higher degree of proficiency that offers distinct career opportunities in specialized areas of nephrology. Transplant nephrology, for example, would likely continue to occur during an additional year of nephrology fellowship. As previously noted, federal funding for additional training would require accreditation by ACGME.

At a more granular level, ASN will need to define a consistent taxonomy, lexicon, and terminology in nephrology; inventory and publicize current offerings for individualized pathways at ACGME-accredited training programs; ensure the updated fellowship training program requirements meet the objectives for Level I competency; and coordinate with existing initiatives (by ASN, such as the society's Home Dialysis Task Force, or by other members of the kidney community) to develop necessary curricula for high-priority gaps in nephrology.

Recently, ASN made two operational changes to help facilitate these efforts. First, every element of planning for ASN Kidney Week was separated from the society's other educational efforts, such as the ASN Board Review Course & Update, nephSAP (the Nephrology Self-Assessment Program), or KSAP (the Kidney Self-Assessment Program). This separation ensures educational independence for Kidney Week to continue featuring scientific and clinical excellence as well as allows ASN to better coordinate all of its other educational offerings in alignment with the task force's recommendations. Second, ASN has suspended all efforts to develop curricula (and related activities) until the new oversight task force has time to organize.

Strengthen the health care workforce in nephrology and address current workforce challenges

In its final report, the ASN Task Force on the Future of Nephrology dedicated two of its 10 recommendations specifically to strengthening the health care workforce in nephrology:

  • Ensure equal opportunities for all nephrologists (Recommendation 8). “Nephrology must work toward ensuring all nephrologists—including allopathic, osteopathic, international medical graduates (IMGs), and US-IMGs—have equal opportunities in the United States.”

  • Foster interprofessional and interdisciplinary practice (Recommendation 9). “Nephrology must emphasize the importance of interprofessional and interdisciplinary practice that involves all members of the health care team in the care of people with kidney diseases.” According to the task force, the interprofessional kidney care team should include advanced practice providers, care managers, community health workers, dietitians, nephrologists, nurses, occupational therapists, pharmacists, physical therapists, psychologists, researchers, social workers, and others as appropriate to the needs of the patient and family.

Representatives from the ASN Policy and Advocacy Committee (chaired by Roslyn B. Mannon, MD, FASN), Quality Committee (chaired by Scott D. Bieber, DO), and Workforce and Training Committee have been working with the society's staff to discuss ways to strengthen the health care workforce in nephrology and address current challenges to the nephrology workforce. In addition to helping implement the task force's two recommendations, this advisory group must work with the rest of the kidney community—especially organizations like the American Nephrologists of Indian Origin, American Nephrology Nurses Association, and RPA—to:

  1. Overcome shortages of nephrologists and other health professionals, particularly nephrology nurses caring for dialysis patients, throughout the United States.

  2. Support IMGs, who represent 50.5% of the 11,407 nephrologists currently in practice in the United States (11).

  3. Expand access and optimize the way kidney care is delivered.

  4. Address the paradox between current and future shortages of nephrologists and other nephrology health professionals versus the need to right-size the number of nephrology fellowship training positions (12, 13).

  5. Ensure work-life balance, address burnout, and provide high-quality kidney care, especially after nearly 3 years of the COVID-19 pandemic (14).

Both the task force and this advisory group have agreed that addressing concerns about the research workforce in nephrology will require an entirely separate, dedicated, and well-resourced effort. ASN should pursue such an undertaking as soon as possible, perhaps working directly with organizations such as the Association of American Physicians, The American Society for Clinical Investigation, and the American Physician Scientists Association.

In closing, I invite every member of the kidney community to thank the members of the task force, ABIM and ACGME advisors, ASN staff, and the individuals and organizations who contributed to the interim and final reports (15). Specifically, I commend former ASN President Mark E. Rosenberg, MD, FASN, and ASN Senior Director of Strategic Relations and Patient Engagement Melissa R. West for chairing and administering the task force, respectively. They were heroic.