The ultimate goal of nephrology fellowships is to provide trainees with a well-balance curriculum allowing for the progressive attainment of knowledge and skills requisite to deliver unsupervised care of patients with kidney disease. Along the way, it is imperative for trainees to attain the necessary communication skills needed to work as a member of a medical team enabling positive interaction with patients, caregivers, and members of the medical team. Fellowship training is unique in that trainees have already completed internal medicine training. Thus, the trainee has been deemed competent to practice internal medicine without supervision. This allows for fellowship programs to focus on teaching specialized skills pertinent to the field of nephrology. The Accreditation Council for Graduate Medical Education (ACGME) is introducing a new concept in how all medical and surgical subspecialties identify important “milestones” in a learners training to establish when they are “competent for unsupervised practice”.
As a scientist, I have always believed in quantification. It is challenging to truly understand anything without a metric to measure against. However, metrics for “milestones” in medical training have yet to be completely developed or even defined. A recent editorial in AJKD by Yuan et al outlines quantitative objective milestones currently in place at the fellowship training program at Walter Reed National Military Medical Center in Bethesda, MD. They suggest that these milestones can been used and adapted to produce the Nephrology Specific Milestones that will be implemented by the ACGME to guide the quality of medical education in Nephrology.
The way medical residents and fellows are evaluated during their training experience differs considerably from program to program. In 2012, the ACGME introduced the Next Accreditation System (NAS http://www.acgme-nas.org/) in order to allow for comparisons between programs and for a true educational trajectory approach to learning. The purpose of the NAS is to improve future physician practice using a peer-review system. Nephrology fellowship programs are just now beginning to develop their own milestones, and the article by Yuan et al can serve as a framework. Phase I of the NAS included diagnostic radiology, emergency medicine, internal medicine, neurological surgery, orthopaedic surgery, pediatrics, and urology, with implementation having occurred on July 1, 2013. Subspecialty milestones (including nephrology) will be developed in 2013-2014 and introduced between 2014 to 2015. After milestones from nephrology are developed, they will be implemented by programs throughout the country. However, it is not clear how the ACGME will use the data that is generated. It is clear that ABIM board examination performance and some sort of analysis of patterns and rates of progression toward milestone achievement will be used.
Yuan et al provide the rationale for selecting their milestones. They suggest that milestones in nephrology should:
1. Be nephrology focused
2. Be quantitative and objective when possible
3. Focus some milestones on nephrology procedures
4. More is not better
5. Attempt to validate milestones must be made
6. Clearly define tools
The nephrology milestones (described in Table 1) are divided into the 6 core competencies, and further broken down to fellowship year 1 and year 2 milestones. Unique attributes of the milestones included clinic chart audits. In their schema, 100% of the trainee’s clinic charts are audited during the first 6 months of training. If the trainee is able to have less than 5% of encounter deficiencies (for timeliness, use of guidelines for CKD/hypertension) then only 50% of charts are audited in months 7-9, This further decreases to 25% if the trainee is able to keep their deficiencies less than 5%. Other milestones include 360 degree evaluations, mini-clinical evaluation exercises, evaluations from presentations, completion of urinalysis and medical ethics modules, and procedure logs for kidney biopsies, catheter insertions, and long-term hemodialysis.
Another change implemented by the NAS is how trainees will be assessed. Instead of the familiar 1-5 rating system (which always skewed ratings to the top regardless of the trainees’ experience).The rating options from the NAS will be a 1-9 scale. This will hopefully allow for a more graded approach to evaluating residents and fellows. For example, a rating of 9 corresponds to a level 5 or aspirational level. This is reserved for residents and fellows who are beyond “Ready for Unsupervised Practice,” which is a level 4 or a rating of 7. In this system, only very advanced fellows should ever receive a rating above 7. This approach is attractive and will hopefully allow the trainee to actually receive some sort of feedback when reviewing these ratings. This has always been a difficult task from both the fellow and faculty perspective. However, the same skewing of data could continue to plague this system as well, especially in small programs where critical feedback can sometimes cease to exist. In order to circumvent this, each program will be required to form a Clinical Competency Committee. This committee will be composed of key faculty members and will review progress of each trainee and provide rating using the 1-9 scale as described above. Furthermore, they will formally decide whether the trainee is progressing satisfactorily toward achieving competence for unsupervised practice.
Overall, these changes will hopefully allow for a more cohesive way of evaluating fellows. However, it is still unknown how metrics collected will actually lead to better patient care. Furthermore, adoption of these new milestone metrics will take a unified commitment from faculty members. The approach that Yuan et al take to applying milestones to their nephrology training program will help in eventually building milestones that can be used by other programs throughout the US.
Dr. Matthew A. Sparks
eAJKD Advisory Board member