Novel educational approaches to enhance learning and interest in nephrology

Online-to-offline combined with problem-based learning is an effective teaching modality in the standardized residency training of nephrology

BACKGROUND

The online-to-offline (O2O) teaching method is recognized as a new educational model that integrates network learning into offline classroom education, while problem-based learning (PBL) is a teaching modality that guides students to apply acquired theoretical knowledge to solve practical problems. However, implementing O2O combined with PBL has not been extensively explored in nephrology residency training. This study aims to explore the efficacy of O2O combined with PBL in the standardized residency training of nephrology by comparing it with the traditional lecture-based teaching (LBT).

METHODS

Sixty residency trainees who participated in the standardized training of internal medicine in the nephrology department of the Second Affiliated Hospital of Zhejiang University School of Medicine were equally allocated into O2O combined with PBL (O2O/PBL) or the LBT group demographically matched. Examinations of theory, practice skills, clinical thinking and teaching satisfaction surveys were utilized to assess the teaching effects of the two groups.

RESULTS

Participants from the O2O/PBL group outperformed those from the LBT group in the examination of theory (81.233 ± 9.156 vs. 75.800 ± 7.009, mean ± SEM), practice skills (104.433 ± 3.569 vs.100.316 ± 4.628, mean ± SEM) and clinical thinking (88.933 ± 4.473 vs. 86.667 ± 3.844, mean ± SEM). There was no significant difference in the teaching satisfaction between the two groups.

CONCLUSION

The current study shows the positive impact of O2O combined with PBL approach on standardized residency training in nephrology without reducing teaching satisfaction.

Engendering a Love of Nephrology Among Medicine Residents: Education Over Recruitment

Dwindling interest in nephrology amid a growing prevalence of kidney disease has inspired nephrologists to create educational initiatives for trainees. Engagement at all levels is crucial to fostering interest in the field, and experience for internal medicine residents has been a significant area for growth. In this article, we review the literature on available educational programs at the residency level. These interventions were largely met with high trainee satisfaction and positive feedback, particularly when designed with the goal to create superb internists rather than future nephrologists. Based on the available literature and our own experience at the University of Pennsylvania, we propose that such approaches will be better-received and engender a greater love for nephrology.

Flipped classroom combined with case-based learning is an effective teaching modality in nephrology clerkship

BACKGROUND

The flipped classroom (FC) is recognized as an effective teaching approaches by emphasizing on the development of high-order abilities; however, the implementation of FC has not been well explored in nephrology education. The present study aims to investigate the efficacy of FC in teaching nephrology via comparing with the traditional lecture-based teaching (LBT).

METHODS

Sixty-two medical clerkship students at Zhejiang University School of Medicine were equally allocated into either LBT or FC group demographically matched. The glomerular diseases module was chosen for the teaching content. Students from the FC group were required to study the pre-class materials in annotated PPT format in advance. In the class, case-based learning (CBL) was employed, students encountered the related clinical cases and participated in the face-to -face discussion. Students from the LBT group attended a didactic lecture during the class. Quiz and questionnaires were performed to assess the efficacy of FC versus LBT.

RESULTS

Participants from the FC group performed better in the quiz than those from the LBT group with higher total scores (78.06 ± 2.515 vs. 65.16 ± 3.209, mean ± SEM), particularly the scores of the case analysis-related questions (35.81 ± 1.657 vs. 27.42 ± 1.910, mean ± SEM). In the survey, more students considered FC beneficial to comprehension, critical thinking, patient management and team work as compared with LBT. Meanwhile, more participants agreed increased in-class pressure in FC than in LBT.

CONCLUSIONS

This study shows the positive impact of FC combined with CBL approach on nephrology education and provides an alternative pre-class and in-class format for the FC implementation.

A hemodialysis curriculum for nephrology fellows using a blended learning approach: best of both worlds?

A comprehensive, hands-on hemodialysis curriculum during nephrology training is necessary for effective learning and optimal patient care. Traditional instructive approaches are unable to fully meet the needs of the digitally inclined learner and are limited by time constraints and increasing clinical workload. Internet based learning (E-learning) is becoming increasingly popular in medical education and nephrology and gaining even greater relevance in the COVID era. However, it presents technical challenges and may create an environment of social isolation. A ‘blended learning approach’ combines E-learning with traditional methods of teaching and offers advantages over either approach alone. We have designed and implemented a formalized hemodialysis curriculum at our institution that is based on blended learning, utilizing faculty-created E-learning tools combined with traditional pedagogical methods (bed-side and classroom). The web-based tools discuss hemodialysis adequacy, principles of urea transport, hemodialysis access examination and access complications. These tools are open access and structured around the science of cognitive learning using animation, interactivity, self-assessment and immediate feedback features. They have been viewed by a wide audience of nephrologists, dialysis nurses as well as medicine house-staff and have received strong validation in a post-test survey. The online tools have supported a ‘flipped classroom’ instructive model and our blended curriculum has been successfully used for nephrology fellow training at our institution. Incorporating faculty designed/approved E-learning tools to create a ‘blended’ nephrology curriculum for trainees at various levels of medical education, can help streamline active and time-efficient learning, with the goal of improving learner engagement, knowledge acquisition and academic curiosity in the field.

Current Paradigms and Emerging Opportunities in Nephrology Training

Nephrology is facing a period of remarkable and unprecedented change. The pipeline of device and therapeutic drug development, the growing success of clinical trials, and the emergence of novel clinical practice and training pathways each hold the promise of transforming patient care. Nephrology is also at the forefront of health policy in the United States, given the recent Advancing American Kidney Health initiative. Despite these developments, significant barriers exist to ensure a robust pipeline of well-qualified nephrologists, including but not limited to trainees' declining trainee interest in the specialty, lower board pass rates, and a perceived erosion in stature of the subspecialty. There is a lack of consensus among training program directors regarding procedural training requirements, the number of fellowship positions needed, and the value of the match. There is widespread agreement, however, that any initiative to reassert the value of nephrology must include significant focus on reinvigorating the trainee experience before and during fellowship. We discuss the current state of education in nephrology (from medical school to beyond fellowship) and highlight ways to increase interest in nephrology to reinvigorate the specialty.

The Transplant Nephrology Workforce in the United States: Current State and Future Directions

The population of patients with kidney transplants in the United States is growing. The delivery of transplant care is complex, involves a multidisciplinary transplant team, and care coordination between transplant and community providers. The transplant nephrologist is central to the delivery of this care and assumes a multitude of clinical and nonclinical roles and responsibilities. With a growing population of patients requiring transplant care that spans a continuum from pretransplant referral to long-term posttransplant management, an understanding of the current state of the transplant nephrology workforce in the United States and the future that it faces is important in ensuring that current and future needs of both patients and physicians are met. In this article, we (1) review the scope of practice of the transplant nephrologist, (2) discuss the state of training in the field of transplant nephrology, (3) review the role of the referring primary nephrologist in the care of patients undergoing kidney transplant, and (4) discuss challenges and opportunities facing the transplant nephrology workforce.

Theories of learning and teaching methods used in postgraduate education in the health sciences: a scoping review

OBJECTIVE

The objective of this scoping review was to determine the theories of learning and methods used in teaching in postgraduate education in the health sciences. The longer-term objective was to use the information gathered to design a workshop for teachers of postgraduate students.

INTRODUCTION

Whilst undergraduate teaching in the health sciences has received considerable attention in the literature in terms of methods used, innovative ideas and outcomes, the same cannot be said of postgraduate education. A considerable amount of postgraduate teaching takes place in the workplace and often in the form of informal teaching. The increasing complexity of health problems calls for innovative teaching.

INCLUSION CRITERIA

Papers included in this review were those that considered postgraduate education in the health science disciplines, including but not limited to medicine, nursing, occupational therapy, physiotherapy, pharmacy and dentistry, and that described theories of learning and/or teaching methods used in teaching.

METHODS

Five databases were searched for the period 2001 through 2016. PubMed yielded the most records (3142). No relevant papers were identified through hand searching of the references of the included papers. A data extraction table was developed and used to extract relevant information from included papers.

RESULTS

Sixty-one papers were included in the review. Most of the included papers were from the USA, with 17 published in 2015. Descriptive study designs were the most frequently identified study design. Most of the papers were from the medical disciplines. Twenty-seven papers did not refer to a teaching and learning theory, a further group referred to a theory but often towards the end of the paper, and seven papers had as their focus the importance of theories in medical education. The theories named were of a wide variety. Likewise, a wide range of teaching methods were identified.

CONCLUSIONS

It is clear that a range of theories and teaching methods are used in postgraduate health science education, with educators feeling the need to explore more innovative methods.

Kidney Mentoring and Assessment Program for Students: a guide for engaging medical students in nephrology

Background

The American Society of Nephrology's (ASN) Workforce Committee created a unique program called the Kidney Mentoring and Awareness Program for Students to engage medical students in the fight against kidney diseases and interest them in careers in nephrology.

Methods

The program provided a framework and 2 years of funding to three medical schools to organize and carry out health screenings in underserved areas of their communities as well as a structure for student mentoring by the practicing nephrologists.

Results

The Workforce Committee identified three medical schools (Emory University, Atlanta, GA; Indiana University, Indianapolis, IN and University of Louisville, Louisville, KY) and engaged faculty at each school to serve as advisors. The ASN committed funding to the groups for 2 years, after which the groups became self-sufficient. Three nephrologists participated in each chapter, building on existing relationships with community groups to identify sites and carry out kidney screening events.

Conclusions

We report here the experience of those chapters and a blueprint for other schools interested in setting up a similarly structured program to interest students in nephrology while working with community groups to spread awareness of the major underlying causes of kidney disease.

'WhatsApp®'ening in nephrology training

Background

Teaching methods in most residency and fellowship programs have not yet addressed the challenges of rapid dissemination of new scientific information. Our Northwell nephrology fellowship program used the smartphone application WhatsApp^® to facilitate nephrology education. A qualitative study was conducted to explore perceptions of nephrology fellows and faculty using WhatsApp^® as a teaching tool.

Methods

A WhatsApp^® messenger group called ‘Northwell Renal Forum’ was created in 2018, which included all eight fellows and seven selected faculty members. Multiple choice questions on various nephrology topics were posted, about one to two per week. Fellows responded at their leisure. After 7 months, data were analyzed following two 1-h focus groups (one for faculty and one for fellows). Focus groups were moderated by two qualitative researchers, unknown to the participants, who asked open-ended questions about the WhatsApp^® learning approach.

Results

Faculty feedback was generally positive. Three major themes arose: control over learning material, comfort being fostered between faculty and fellows and faculty perceptions of fellows. The fellows also reported an overall positive experience. Control and comfort were themes again identified in this focus group. Fellows reported feeling control over which faculty member was in the group and when to respond to questions. Fellows also felt comfort from learning without pressure. Variety was the third theme that arose.

Conclusion

Focus group evaluations elucidated the strengths of using WhatsApp^®, and the overall positive experience of both faculty and fellows. This inexpensive and easy-to-use tool can augment the learning of nephrology during fellowship.

An Interactive Ambulatory Nephrology Curriculum for Internal Medicine Interns: Design, Implementation, and Participant Feedback

While diminishing nephrology fellow recruitment is a known issue, more work is needed to evaluate possible interventions to reverse this trend. We designed and implemented a curriculum to increase exposure to ambulatory nephrology among internal medicine interns. The curriculum focused on key aspects of outpatient nephrology practice, including supervised clinic visits, formal themed didactic content, and an online interactive forum with assigned evidence-based readings and small-group responses to relevant cases. We obtained postcourse surveys from all participating interns. Of the 43 interns who took part in the first year of the ambulatory nephrology curriculum, 100% reported a positive didactic experience and 91% reported a positive interactive online experience. 77% reported an improvement in their familiarity with clinical nephrology practice (median 2-point increase in familiarity score on a 7-point scale, P<0.001 by signed rank testing). Qualitative feedback included praise for the high-yield topics covered by the lectures and energizing teachers. In conclusion, we successfully implemented an ambulatory nephrology curriculum using a framework that integrated formal didactics, interactive online learning, and key clinical components of outpatient nephrology care. Future investigation will evaluate whether early implementation of this curriculum is associated with increased pursuit of nephrology as a career.

Education in Nephrology Fellowship: A Survey-Based Needs Assessment

Educational needs assessments for nephrology fellowship training are limited. This study assessed fellows' perceptions of current educational needs and interest in novel modalities that may improve their educational experience and quantified educational resources used by programs and fellows. We distributed a seven-question electronic survey to all United States-based fellows receiving complimentary American Society of Nephrology (ASN) membership at the end of the 2015-2016 academic year in conjunction with the ASN Nephrology Fellows Survey. One third (320 of 863; 37%) of fellows in Accreditation Council for Graduate Medical Education-accredited positions responded. Most respondents rated overall quality of teaching in fellowship as either "good" (37%) or "excellent" (44%), and most (55%) second-year fellows felt "fully prepared" for independent practice. Common educational resources used by fellows included UpToDate, Journal of the American Society of Nephrology/Clinical Journal of the American Society of Nephrology, and Nephrology Self-Assessment Program; others-including ASN's online curricula-were used less often. Fellows indicated interest in additional instruction in several core topics, including home dialysis modalities, ultrasonography, and pathology. Respondents strongly supported interventions to improve pathology instruction and increase time for physiology and clinical review. In conclusion, current nephrology fellows perceive several gaps in training. Innovation in education and training is needed to better prepare future nephrologists for the growing challenges of kidney care.

Enhancing outpatient nephrology experience for internal medicine residents

Interest in nephrology careers continues to remain low in the USA. Educational innovations that enhance interest in nephrology among medical trainees are being actively studied. While internal medicine (IM) residency programs commonly offer the inpatient nephrology elective to the resident, outpatient nephrology experience is lacking. Understanding the provision of care in outpatient and home dialysis and management of patients with glomerular diseases, chronic kidney disease and kidney transplantation are vital components of an outpatient nephrology rotation. In this review article, we share our experiences in incorporating outpatient nephrology to the IM resident's elective time. We also present the structure of the nephrology rotations at our programs and suggest several learning opportunities in outpatient nephrology that the training community can provide to medical residents. Strategies to effectively set up an outpatient nephrology rotation are also described. While more educational research on the impact of outpatient nephrology on resident learning and career choices are needed, we encourage a collaborative effort between faculty members in nephrology and the medicine residency programs to provide this unique learning opportunity to IM residents.

Career interest and perceptions of nephrology: A repeated cross-sectional survey of internal medicine residents

Background

Interest in nephrology careers among internal medicine residents in the United States is declining. Our objective was to assess the impact of the presence of a nephrology fellowship training program on perceptions and career interest in nephrology among internal medicine residents. A secondary objective was to identify commonly endorsed negative perceptions of nephrology among internal medicine residents.

Methods

This was a repeated cross-sectional survey of internal medicine residents before (Group 1) and 3 years after (Group 2) the establishment of nephrology fellowship programs at two institutions. The primary outcome was the percentage of residents indicating nephrology as a career interest in Group 1 vs. Group 2. Secondary outcomes included the frequency that residents agreed with negative statements about nephrology.

Results

131 (80.9%) of 162 residents completed the survey. 19 (14.8%) residents indicated interest in a nephrology career, with 8 (6.3%) indicating nephrology as their first choice. There was no difference in career interest in nephrology between residents who were exposed to nephrology fellows during residency training (Group 2) and residents who were not (Group 1). The most commonly endorsed negative perceptions of nephrology were: nephrology fellows have long hours/burdensome call (36 [28.1%] of residents agreed or strongly agreed), practicing nephrologists must take frequent/difficult call (35 [27.6%] agreed or strongly agreed), and nephrology has few opportunities for procedures (35 [27.3%] agreed or strongly agreed). More residents in Group 2 agreed that nephrology is poorly paid (8.9% in Group 1 vs. 20.8% in Group 2, P = 0.04), whereas more residents in Group 1 agreed that nephrologists must take frequent/difficult call (40.0% in Group 1 vs. 18.1% in Group 2, P = 0.02).

Conclusions

The initiation of a nephrology fellowship program was not associated with an increase in internal medicine residents’ interest in nephrology careers. Residents endorsed several negative perceptions of nephrology, which may affect career choice.

Medical student attitudes toward kidney physiology and nephrology: a qualitative study

Interest in nephrology among trainees is waning in the USA. Early perceptions and attitudes to subject matter can be linked to the quality of pre-clinical curricula. We wanted to explore these attitudes in the setting of modern curriculum redesign. We utilized Q methodology to understand first-year medical student attitudes after an innovative kidney physiology curriculum redesign that focuses on blending multiple learning methods. First-year medical students were invited to take a Q sort survey at the conclusion of a kidney physiology course. Students prioritized statements related to their understanding of kidney physiology, learning preferences, preferred course characteristics, perceived clinical relevance of kidney physiology, and interest in nephrology as a career. Factor analysis was performed to identify different student viewpoints. At the conclusion of our modified course, all students (n = 108) were invited to take the survey and 44 (41%) Q sorts were returned. Two dominant viewpoints were defined according to interest in nephrology. The Potentials are students who understand kidney physiology, perceive kidney physiology as clinically relevant, attend class sessions, utilize videos, and are willing to shadow a nephrologist. The Uninterested are students who are less satisfied with their kidney physiology knowledge, prefer to study alone with a textbook, avoid lectures, and are not interested in learning about nephrology. In an updated renal physiology course, students that use multiple learning methods also have favorable attitudes toward learning kidney physiology. Thus, modern curriculum changes that accommodate a variety of learning styles may promote positive attitudes toward nephrology.

Applying effective teaching and learning techniques to nephrology education

The interest in nephrology as a career has declined over the last several years. Some of the reasons cited for this decline include the complexity of the specialty, poor mentoring and inadequate teaching of nephrology from medical school through residency. The purpose of this article is to introduce the reader to advances in the science of adult learning, illustrate best teaching practices in medical education that can be extrapolated to nephrology and introduce the basic teaching methods that can be used on the wards, in clinics and in the classroom.