Are Nephrology Fellows Doing Enough Procedures? Give It Up or Get It Back?

Dr Edward ClarkNephrology fellows have traditionally been trained in the placement of femoral and internal jugular catheters for dialysis. With improvements in the quality of care provided by vascular surgeons and interventional radiologists, many centers have noticed a dip in nephrologists doing such procedures. In recent article published by the American Journal of Kidney Diseases, Clark and colleagues explore the experience of nephrology fellows in Canada in placing temporary hemodialysis catheters. Corresponding author Dr. Edward Clark (EC) from the University of Ottawa, Ontario, Canada, discusses the procedural competency for our trainees in nephrology with Dr Kenar Jhaveri (eAJKD), eAJKD Blog Editor.

eAJKD: Can you briefly summarize your findings?

EC: We conducted a survey of nephrology trainees across Canada regarding their procedural skills in placing temporary dialysis catheters. We found over one-third of respondents indicated that they were not adequately trained to competently insert temporary hemodialysis catheters at both the femoral and internal jugular site. In addition, there was a lot of room for improvement in terms of the increased use of evidence-based infection control techniques and ultrasound guidance, when placing catheters.

eAJKD: Many centers don’t require internal medicine residents to do procedures, and some have ICU fellows and ICU rotating residents place most of the dialysis catheters. Is that having significant impact on our fellows training, and do you think that accounts for your findings?

EC: I am double boarded in critical care and nephrology. What you describe was certainly the case where I trained. Nephrologists were not as involved, and that prompted me to see if this was the trend nationwide. Our manuscript does highlight that nephrology trainees are not doing enough of these procedures. Since the patient is getting the access, we can assume it is by either ICU physicians, radiology, or vascular surgery.

eAJKD: In the US, more than 60% of our nephrology trainees are international medical graduates. Do you think that might be a cause for this trend?

EC: It’s possible, but most of those fellows presumably did an internal medicine residency in the US and would have gained some procedural skills during their experience. On the other hand, there are significant changes taking place to internal medicine training programs with less of an expectation for residents to place catheters. This will have implications for the incoming cohort of nephrology trainees.

eAJKD: What do you foresee happening with the kidney biopsy procedure? Do you think it’s going to meet a similar fate?

EC: Based on my observations, it looks like the kidney biopsy procedure is being lost by nephrologists, but I don’t have much data to support this. It is certainly a trend noted for temporary hemodialysis catheters. As educators, we need to make solid arguments that nephrologists should be capable of placing temporary catheters. And as a result, we should be training fellows to insert them. While kidney biopsy may be an urgent diagnostic procedure, catheter placement can sometimes be an integral component of life-saving treatment. As such, I feel that the catheter placement procedure is important to nephrology, and should continue to be taught in fellowship.

eAJKD: What if faculty don’t feel comfortable doing these procedures due to lack of their training given the above circumstances?

EC: This is where simulation centers might help. Other options can be training under the supervision of the ICU attending, interventional radiologists, or vascular surgeon. These are alternate ways programs can train their fellows.

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