Nephrology fellowship training in the 21st century: where do we stand?

S ubspecialty training in nephrology is evaluated and accredited by the Accreditation Council for Graduate Medical Education (ACGME). The goal of this private, nonprofit council is to improve health care by assessing and advancing quality of physicians’ education through accreditation (1). The American Board of Internal Medicine (ABIM), also a private, nonprofit evaluation organization, is charged with enhancing the quality of health care by certifying subspecialists and ensuring that physicians have the clinical judgment, skills, and attitudes that are essential for the delivery of excellent patient care (2). Both of these organizations are ultimately accountable to the profession of medicine and to the public. Nephrology training program directors (TPDs) are entrusted with the responsibility of ensuring that fellows are competently trained in the nephrology subspecialty, with the overriding goal to create physicians who are capable of providing competent, quality care to patients with kidney disease. What is considered “competent training” has evolved over time and continues to change with each passing year. Adoption of the six core competencies was an initial step in the process. In recent years, the ACGME stipulated the institution of more regulations on various aspects of subspecialty training. The major mandates include a reduction in duty hours to reduce physician stress and fatigue, emphasis on competency-based curricular development and competency-based training and evaluation, and ultimately milestone-based education and competency. Although the ACGME recommends various evaluation tools to verify fellow competency and ABIM tests primarily medical knowledge, TPDs are often left with incomplete data to judge their performance in all areas of fellow training. Currently used evaluation tools can only partially examine competency areas. Some useful data on perceived competency of recent fellowship graduates are garnered from postgraduate surveys, but these provide only limited, local feedback. The article by Berns in this issue of CJASN is timely in providing TPDs with general feedback about the strengths and weaknesses of fellowship training in recent years (2004 to 2008) (3). These are sorely needed data because the last survey of nephrology fellowship training adequacy was published in 1991, reflective of training more than 2 decades ago (4). Berns surveyed American Society of Nephrology (ASN) members on their perceived competency in fellowship training in a number of nephrology areas and the importance of these areas in their current practice (3). It is interesting that a diverse response from the 133 physicians was noted, some expected and some surprising. Most respondents (92.4%) were trained in US nephrology training programs, and 93% were ABIM certified in nephrology. There was equal representation from academic medical centers and private practice, whereas only approximately 5% were from industry or research. Approximately 98% were involved in some form of patient care. As one might expect, hospital-based nephrology practice, transplant nephrology, and in-center hemodialysis were generally viewed as adequately taught by training programs. Most of the “bread and butter” areas of nephrology were well covered in fellowship training. It was not surprising that procedures that are currently considered under the domain of “interventional nephrology” were rated deficient, because few programs offer interventional training. Training in business and administrative aspects of nephrology, considered important to clinical practice, were areas of perceived weakness. Unfortunately, previously noted deficiencies (acute and chronic peritoneal dialysis, plasmapheresis, and nutrition) remained a problem. Endof-life/palliative care and geriatric nephrology training, which have received increased attention in the past decade, fell short. Basic/bench research, more so than clinical research, was identified as a deficient training area, as was education in securing research funding from various agencies. This in part reflects the limited number of fellows who enter training programs and are interested in a research career. Table 1 summarizes competency perception as deficient, sufficient, and borderline. So what are those in the business of training future nephrologists to do with this information? The obvious answer is to identify and programmatically focus our training on the areas of concern; however, there are two major impediments to achieving this goal. First, we need feedback more frequently than every 20 years. Second, it is difficult for any single training program to cover all of these topics sufficiently to ensure competent training. In regard to the first issue, one initiative that will help TPDs identify deficient training areas on a more regular basis is already under way. The ASN has been a crucial Published online ahead of print. Publication date available at www.cjasn.org.