Caring for the Kidney Patient in the Future: Rethinking Nephrology Training Programs

A recent editorial in the Clinical Journal of the American Society of Nephrology discusses the imperatives in the training of the future generation of nephrologists (1). In this insightful presentation Kohan notes five of the key forces that are driving what he calls a “perfect storm” in our discipline. The forces include increasing clinical workload, diminished interest in nephrology as a career choice, the changing nature of nephrology care, increased requirements for nephrology training programs from accreditation bodies and decreased funding for nephrology trainees and research. Mentioned as well is the excellent study by Berns published in 2010 demonstrating the dissatisfaction nephrologists had with the real-world preparation they received during their fellowship training (2).

Nearly seven years ago, we published a Special Article in Seminars in Dialysis following a preceptorship we organized for second-year nephrology fellows (3). This multi-day program, carried out by senior leaders in nephrology was attended by nearly 70 fellows, many from some of the most acclaimed nephrology training programs in the United States. As part of the experience we surveyed the participants to better understand the training programs from which they came. We were astonished by the responses, including:  50 percent of programs offered fewer than three months of experience in OP hemodialysis; 25 percent of programs offered no exposure to chronic peritoneal dialysis; 50 percent of programs offered fewer than three months of inpatient dialysis; and two-thirds of programs offered fewer than three months of transplantation. Faculty rounding during the OP dialysis rotation was “prn” in 25 percent of programs.

We made a series of recommendations to improve the fellowship experience and align what fellows are taught with what they need to know when they enter practice. These include: continuity experience in outpatient dialysis (minimum of three months, preferably 12 months); exposure to all available forms of RRT including HD, PD, HDF, and CRRT; exposure to daily and nocturnal dialysis as well as HHD; exposure to interventional nephrology; regular multidisciplinary rounds with faculty and other care team members on a regular basis; and regular didactic lectures on relevant topics related to dialysis and the management of ESRD and CKD patients.

This list is now incomplete, as pointed out in the excellent study by Lane and Brown published in the same issue of CJASN as the Kohan editorial. These authors from Australia point out that in order to truly be a world class nephrologist, one must have the content knowledge, as outlined in our recommendations above, but also must be trained in delivering holistic care, in developing the necessary skills to apply the knowledge, the be sympathetic/empathetic and to be a superior communicator.

So the challenge goes to our nephrology training program directors – how can they adequately deal with the external forces outlined by Kohan, provide the content knowledge that grows every day and develop a new generation of compassionate communicators?  Not an easy task, but unless we all dedicate ourselves to helping making this possible, it will not happen and one of the last remaining great medical subspecialties will be struggling for survival.

Do the words of the late John F. Kennedy apply to nephrology of the future?

“We have the power to make this the best generation of mankind in the history of the world or to make it the last.”

I look forward to your comments, until next time.

Striving to bring quality to life,
Allen R. Nissenson, MD

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References:

1.    Kohan DE. Training the next generation of nephrologists. Clin J Am Soc Nephrol 6:  2564-2566, 2011.
2.    Berns JS. A survey-based evaluation of self-perceived competency after nephrology fellowship training. Clin J Am Soc Nephrol 5:  490-496, 2010.
3.    Nissenson AR, Agarwal R, Allon M, Cheung AK, Clark W, Depner T, Diaz-Buxo JA, Kjellstrand C, Kliger A, Martin MJ, Norris K, Ward W, Wish J. Improving outcomes in CKD and ESRD patients:  Carrying the torch from training to practice. Seminars in Dialysis 17:  380-397, 2004.