The “Shaping the Future of Nephrology Education” session was held at the ASN KidneyWk on Oct 26, 2018.
This Kidney Week session, always filled with wonderful innovations in education, was moderated by two leaders in nephrology education Melanie Hoenig (@melhoenig) and Vandana Niyyar (@vandyniyyar). We will briefly highlight each presentation below.
The first presentation of the session was from Pravir Baxi (@Proximal_Baxi). GlomCon (@GlomCon) is an online consortium focusing on improving education, clinical care, and research in glomerular disorders. The GlomCon consortium was started in 2016 by Ali Poyan Mehr (@poyanmehr). In 2017, GlomCon was one of the winners of the ASN Innovation in Kidney Education contest for their proposal to add trivia and case conferences geared towards fellows to their already popular platform of video-based live conference style interactive lectures. This year, GlomCon also received the #NephJCKidneys Nathan Hellman Social Media Innovation of the year for their dedicated fellows’ curriculum.
The presentation started with the history of GlomCon and moved on to a discussion on the fellows’ and nephropathology curriculum. Glomcon occurs every Tuesday morning at 11 am EST. Fellowship programs around the country are invited to present a 1-hour live lecture streamed on video conference. The presentations have an interactive element in which participants watching the session can answer questions real-time using embedded software, ask questions to the presenters, and have a simultaneous discussion in a chat room. The organizers do a nice job moderating the simultaneous chat and ensure that questions are answered either by the discussants or participants.
All GlomCon sessions are recorded for later viewing for those unable to attend. The curriculum has been extremely popular and has wide buy-in from participants all over the world. It was impressive to see how many countries are represented. The curriculum was very well-received, with almost 98% of survey respondents either agreeing or completely agreeing that the curriculum contributed to their glomerular knowledge (n = 266). Timing of the conference was noted as a barrier that would prevent some participants from attending the live lecture.
Congrats to the group for maintaining a high quality educational offering in nephrology on a weekly basis! Truly inspirational.
Teaching glomerular disorders was a common theme in the education session during Kidney Week 2018 and represents a recurring gap in education for trainees. This presentation was performed group-style from Baylor College of Medicine in Houston. This was a nice touch and the group demonstrated how to actually administer the tool in real time. The presentation was led by Rajeev Raghavan (@jeevsmd) and Ahmed Awan with help from Prejith Rajendran (@Raj_NephroCrit) and Sehrish Ali (@sehrish_alii).
The teaching tool is a 4-page worksheet (available here), which is organized by placing various glomerular disorders on rows descending from common to rare disorders. Learners go through the worksheet by filling out each of the columns from clinical presentation/pathophysiology, treatment, and prognosis. The facilitator/teacher has a completed worksheet and helps learners fill in gaps if others in the room are unable to answer.
The best part of the tool is the ability to use the completed worksheet as a study aid in the future. Survey results (n = 42) indicated positive results, with 90% of users who agreed that the guide was easy to complete and 85% who planned to use it in the future as a study aid. Overall, this is a convenient and organized way to cover a large amount of material quickly. Congrats to the team and thanks for sharing the tool for everyone to use!
Easing the Difficult Job of Giving “Bad News”: Using a Decision Aid to Match Patient Values to a Dialysis Modality
It can be challenging to discuss which particular dialysis modality is right for a given patient. In order to effectively communicate, it is imperative that the physician both elicit specific patient values and use this information to ensure decisions match. Therefore, the next group discussed the use of a decision aid to help in this discussion. Akhtar Ashdaq was the presenter of this section and he went through the background, premise, and structure of the intervention. The program went through two phases, in which physicians were audio recorded while they discussed the most appropriate dialysis modality.
The first phase was the control period and the second wave utilized a decision aid. The decision aid is called My Life, My Dialysis Choice (a program produced by the nonprofit, Medical Education Institute). Patients used the decision aid and then results were shared with the physician. The study results were impressive: phase 1 results showed that none of the physicians elicited or addressed patient values. However, the phase 2 data, after the decision aid was deployed, resulted in 97% of physicians eliciting patient values. The most impressive finding is that phase 2 participants had a much higher rate of choosing home dialysis (from 13% to 50%). However, this might not purely be a direct effect of the intervention, but rather could be something intrinsic to the participants of the second phase. Nonetheless, it is an intriguing finding.
As noted after the presentation, there was no mention of conservative measures as a modality chose. Additionally, dealing with “bad news” was mentioned in beginning of the presentation but was not thoroughly discussed or in the intervention. The use of a decision tool seemed to be effective and easy to use. Congrats to the group for conducting an exciting and important study!
No Decision Aid
n = 32
|MD elicited/addressed patients values||0 (0%)||29 (97%)||<0.001|
|Patients inserted their own values||4 (13%)||0 (0%)||<0.001|
|POST-VISIT PATIENT SURVEY|
|Would choose home dialysis||4 (13%)||15 (50%)||<0.01|
|Undecided about a type of dialysis||12 (38%)||6 (20%)||0.134|
The next presentation was Sana Waheed from University of Wisconsin-Madison. This group constructed enduring learning activities (ELAs) as part of their curriculum redesign for medical school in 2016. Their goal was to develop online content in an engaging manner that would allow the learner to access this material at a time that was convenient to them. In order to accomplish this goal, they created simulated cases in which the learner would be able to interact with the environment. The learners receive immediate feedback while going through the cases and their progress is assessed.
The group presented data to suggest that students actually performed better when they utilized ELAs as compared to the traditional approach. However, this might be secondary to the cohort that went through these modules. It would be interesting to see how both of these groups scored on other subject areas in a similar time period. Overall, they were able to create compelling online content and the authors suggest it was more effective than traditional lectures.
However, many questions remain: How will medical school curriculum develop over time? Will this become the new norm where direct interaction with live teachers becomes obsolete? Another concern is how often content would need to be refreshed: Yearly? Every 5 years? These are all questions we will need to answer.
The Acute Dialysis Orders Objective Structured Clinical Examination (OSCE): Results of Administration to 117 Nephrology Fellows Nationwide
Outside of the in-training examination (ITE), very few validated tests exists assessing a Nephrology fellow’s competency with dialysis. Lisa Prince discussed using an objective structured clinical examination (OSCE) as an aid to help fellowship programs evaluate medical knowledge in three acute dialysis scenarios:
- Scenario 1: acute continuous renal replacement therapy (CRRT)
- Scenario 2: urgent outpatient dialysis initiation
- Scenario 3: management of prior to and dialysis prescription for hyperkalemia.
During 2016-2017, a total of 117 nephrology fellows from all over the US participated in this examination. A summary of the findings are summarized in the table below:
|Scenarios||Scenario 1||Scenario 2||Scenario 3|
|Description||Acute CRRT||Urgent outpatient dialysis initiation||Management of prior to and dialysis prescription of hyperkalemia|
|Overall Pass Rate||75%||43%||6%|
|Notes||92% correctly prescribing >20 ml/kg/hour effluent dosage
63% able to calculate CRRT clearance as effluent volume
|75% using correct K+ dialysate
12% able to identify the 2 absolute urgent indications for chronic dialysis initiation
|20% correctly checking for rebound hyperkalemia with 2 separate lab draws
83% were correct in not giving IV sodium bicarbonate as acute medical management for hyperkalemia
Overall, 32% of fellows passed and interestingly, there was no significant difference between the first- and second-year fellow performance. While the second year OSCE and ITE scores showed no correlation, the fellow satisfaction survey indicated that the OSCE was useful in assessing proficiency in ordering acute RRT. It should be noted that instead of multiple choice questions, the OSCE utilized short answer style questions, a testing technique that is uncommon in medical training in the US; therefore, pass rates thresholds will likely be different than multiple choice. Overall, the acute dialysis OSCE represents a new opportunity for assessment of the dialysis prescription and attempts to fill an important gap. It is commendable to see the broad buy-in of the OSCE, which is one of the largest and most successful educational assessment initiatives undertaken in the US outside of society-based in training exams. Bravo! To get involved, click here.
Cynthia Miracle (@CMiracleMD) of UCSD explained how academic fellowships provide excellent clinical training but seldom discuss the business aspects of nephrology as part of their curriculum. As a result, Nephrology Business Leadership University (NBLU) was created to help fellows develop the knowledge and skills needed to successfully transition from fellowship into practice. During NBLU, fellows attend a week-long course filled with interactive workshops and sessions, with topics such as job search, growing a practice, retirement planning, and leadership roles.
Fellows who attended the course did pre- and post-survey to assess improvements in knowledge level in 24 different content domains. The pre-survey found only 2 out of 30 fellows had some instruction in any business aspects of medicine. The comparison of the pre- and post-survey revealed significant knowledge increases in all 24 areas. In addition, 100% of fellows answered that they would recommend NBLU to other fellows.
Overall, this conference is an innovative and effective program for education fellows on their transition from fellowship into practice.
The last oral abstract presentation of the day was from Vanesa Bijol on behalf of the ISN-Clinical Nephropathology Course. This was a very interesting presentation because it dealt with the global paucity of nephropathology resources from around the world. The course is a collaboration between the American Nephrologists of Indian Origin (ANIO) and the International Society of Nephrology (ISN) and was started in 2013. The course directors conducted a survey of current and past participants in order to understand the global distribution of nephropathology resources. The results were very interesting and highlights the needs to ensure both continued education and increased access to resources. They received 293 (59%) responses from 61 countries and results were stratified by World Bank economy classification.
The results were shocking with low-income countries that reported no access to electron microscopy; 50% did not even have a lab to process nephropathology specimens. Things improved with high-income countries but issues persist even then. This was an eye-opening presentation and really puts into perspective the global lack of proper kidney pathology. I would be curious as to how many of these countries are also using GlomCon and other online resources. Hopefully, we will start seeing more ways to share high quality nephrology education and also allow for low-income countries to access much needed nephropathology services.
Many thanks to all of the presenters for sharing these fantastic initiatives!