Since the creation of formal fellowships in Nephrology, not much has changed in what we expect of our fellows. Are our current fellows ready to practice with ease? In an editorial recently published in the American Journal of Kidney Diseases, Dr. Robert Brown (RB) from Beth Israel Deaconess Medical Center, Harvard Medical School, proposes to increase the minimum amount of clinical experience to 18 months and supervised ambulatory clinic time increased to two half days per week. Here, he discusses this topic with eAJKD Blog Editor Kenar Jhaveri (eAJKD).
eAJKD: You feel that the one half day of clinic time is not sufficient for fellows to get adequate training in outpatient nephrology. What is the basis of your proposal?
RB: The complexity of renal clinics has grown tremendously. As our field has moved to more of an outpatient focus, there’s been no increase in clinic time over the training period. To compensate for a lack of time to see more patients, programs have added a host of lectures, conferences, and didactic programs instead of more clinical experience. However, lectures on vascular access, for instance, are not comparable to taking care of more patients with vascular access problems.
eAJKD: Are you concerned about our second and third year fellows’ knowledge base?
RB: As I point out in the editorial, fellows in their second year scored little better than the first years on the ASN In-Training Exam (ITE) with no improvement in the last three years. There’s clearly a serious problem in second year learning of our fellows when they only improve 5%, and only 1% in the third year. Why are they not learning in the subsequent years? I think it’s because many don’t do any clinical training in their second and third years, focusing instead on their research requirement. Adding more clinical experience will improve knowledge. Let’s put this concept to a test and observe what the ITE scores and clinical experience of fellows tells us.
eAJKD:It might not be a learner problem—perhaps this is a teacher-related or environment-related problem. Do you feel the fellows see less general nephrology in 2012?
RB: Since 1968 when I was a fellow, the time a fellow spends on consult service and seeing general nephrology patients has shrunken drastically. In the 1960s, most of clinical nephrology was general nephrology. Now that same clinical time is broken down into transplantation, dialysis, interventional nephrology, and perhaps, other sub-specialties within nephrology. Hence, the fellows see less of general consults. To meet Accreditation Council for Graduate Medical Education (ACGME) requirements, most of the clinical months are divided into these above mentioned segments of nephrology plus protected research time. Hence, fellows are seeing less and less general nephrology.
eAJKD: What are your thoughts on the research requirements for fellows bound towards a career in clinical nephrology?
RB: The idea that a research experience has to be part of the training of every fellow seems to be out of line with what’s needed—better clinicians. Scholarly activity is valuable, but to require dedicated research for clinical fellows does not seem appropriate for a two-year fellowship. Extra time within designated research fellowships is more ideal for training future researchers. But even the “research bound” fellow requires a solid background in clinical nephrology. As we know, many don’t get grants and eventually pursue clinical careers. But for this to happen, there has to be leadership awareness of these concerns by training program directors and the ACGME.
eAJKD: Regarding the procedural component of your manuscript, you mention that 50% of the fellows after graduation do not perform procedures. In United States, I would think the number would be much lower, any thoughts?
RB: The study I quoted in the manuscript was an Australian study where 50% of graduates report that they don’t do procedures. Based on a study by Berns et al, in the United States, nephrologists and nephrology trainees perform native and transplant kidney biopsies in 98% to 99% of programs and insert temporary dialysis catheters in nearly all programs. Many programs either do not specify a minimum number of supervised procedures that need to be performed to demonstrate competence, or require a very limited number. But no recent study has looked at what happens after fellowship in the US. I would guess the numbers are much lower—with only about 20-30% of nephrologists continuing to perform such procedures after fellowship. So we must guarantee competence in these fellows by specifying minimum requirements, but why require every fellow to perform invasive procedures?
eAJKD: What are the challenges to offering two fellowship tracks—a two-year program with 18 clinical months and a research program where the same requirements are extended over three years?
RB: In the certification of nephrologists, fellowships need to assure clinical competence. If you look at my proposed two-year program, there is nothing that says that those 18 clinical months couldn’t be spread over the two years. The only area where I specified year one, two, and three was in the research program. I think the researchers would want fellows to have a “heavy” first clinical year followed by large blocks of time devoted to the laboratory. You could spread the additional clinical requirements over the course of year two and year three. Currently, we’re not allowed to spread it into year three and have it count by the ACGME. Why not?
eAJKD: We would be interested in hearing what our fellows in training have to say.