Kidney News Introduces New Editorial Fellows, Showcases Their Ideas for Improving Training in Nephrology

Training in Nephrology 2023: What Can Be Changed?

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As the only person in my residency class who was applying to nephrology, I have often wondered why many others did not seem as interested in the same specialty. A survey of fellows from different subspecialties other than nephrology showed that “the subject matter being too difficult” was cited as a common reason for not choosing this specialty (1). Although the pre-clinical years of medical school are heavily focused on physiology and cellular pathology, residency medical education is not. Nephrology is a field that is steeped in physiology and if not taught correctly, may deter residents from pursuing it as a future career.

Nephrology is also not heavily tested on board exams. According to the yearly American Board of Internal Medicine exam blueprint, nephrology (combined with urology) makes up 6% of topics tested compared with 14% of cardiology content (2). Also, unlike certain other specialties, nephrology is not a required rotation for many internal medicine residents. My goal is to create a formal curriculum for residents who rotate on nephrology services that will teach them how to apply physiology into daily practice. For example, the topic of hyponatremia can be taught by using clinical cases, with an emphasis on pathophysiology before delving into diagnosis and management. Physiology retreats, such as the one I helped organize during my chief residency year at Virginia Commonwealth University, and the ASN Kidney Tutored Research and Education for Kidney Scholars (TREKS) program are unique ways to re-introduce and solidify physiology concepts into residency training. They allow participants to pose scientific questions related to clinical scenarios they had encountered in their daily practice and to then answer them using basic scientific experiments. This can be done at an institutional or national level, for example, by making the Kidney TREKS program available to residents, as well as medical students.

Nephrology training would benefit from revitalizing the way we teach core physiological concepts. By reminding trainees of the scientific process of making and testing hypotheses, this could not only increase their appreciation of medicine but also lead to innovation and overall better patient care.

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Over the past decade, there has been an incredible interest in reforming nephrology owing to multiple factors. Perhaps the most important factor is the slow decline in the number of nephrology trainees over the past few years, along with the dire need for well-trained nephrologists during the recent COVID-19 pandemic. This signals a much deeper concern about how we recruit, develop, and retain candidates. In the next few lines, I will outline some intriguing ideas to transform how nephrology training could adapt.

1. Nephrology, as a specialty, is evolving to be more evidence based and protocol driven than ever before. Thus, routine dialysis orders and monthly labs should be protocolized by support health care providers to devote nephrology trainees’ time to higher-level critical thinking and planning (e.g., goals of care discussions, access creation, home dialysis transition, mineral/bone disease management, and workup of anemia).

2. Teaching conferences should be tailored to learning styles of trainees (residents and fellows) via online modules, recorded lectures, question banks, and case-based discussions. Frequent iterations of cannot-miss diagnoses and management of acute kidney dysfunction are key to better digestion of nephrology topics that may be off-putting to potential candidates.

3. Most nephrology fellowship programs unfortunately lack balanced exposure to all that a nephrologist does or can do. Exposure to various research methods and study techniques is equally as important as building clinical acumen for dealing with glomerular diseases, onconephrology, and dialysis emergencies.

In conclusion, training in nephrology in 2023 should offer a balanced making of a well-rounded nephrologist, clinician, educator, and scientist.