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McAvoy KA, Gielissen KA, Possick JD, Honiden S. Impact of Ambulatory Blocks on Pulmonary Critical Care Fellow Outpatient Training Experience. ATS Sch 2024; 5:286-301. [PMID: 39055327 PMCID: PMC11270235 DOI: 10.34197/ats-scholar.2023-0130oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/23/2024] [Indexed: 07/27/2024] Open
Abstract
Background The Accreditation Council for Graduate Medical Education requires Pulmonary and Critical Care Medicine (PCCM) fellows spend a minimum of 7% of their time in the outpatient setting over 3 years of training. In a multi-institutional survey, only 47% of PCCM fellows rated their ambulatory training as adequate. Internal medicine residencies previously adopted the "x + y" scheduling model, which separates inpatient ("x") and outpatient ("y") rotations to provide focused ambulatory experiences, to address similar concerns. Objective To observe the effects of dedicated ambulatory blocks at a single academic PCCM fellowship on fellow exposure to outpatient pulmonary medicine, and on fellow and faculty perceptions of education. Methods In the 2021-2022 academic year, PCCM fellows of all class years in a single academic fellowship program in the northeast United States rotated through four 2-week ambulatory blocks that included longitudinal clinics, themed subspecialty clinics, and a dedicated educational half-day for small group learning. Before the intervention, fellow ambulatory clinics were scheduled longitudinally one-half day per week during inpatient and research blocks. Both fellows and faculty were surveyed before and after the intervention; fellows were also interviewed via focus groups at the conclusion of the intervention. The degree of subspecialty clinic exposure was compared before and after intervention. Results There was an increase in the quantity and variety of pulmonary subspecialty clinics per fellow when compared with preintervention years (P < 0.01). After intervention, we observed increased fellow satisfaction with ambulatory education, perceived preparedness for independent practice, and satisfaction with subspecialty clinic exposure (P < 0.05). Faculty satisfaction with fellow ambulatory pulmonary education also increased (P < 0.05). Thematic analysis from focus groups highlighted focused topical learning, exposure to the breadth of pulmonary medicine, career development, interaction with engaged faculty experts, and enhanced interprofessional competence. Conclusion The ambulatory block structure provides a potential model to expand PCCM fellow outpatient pulmonary training through increased exposure to ambulatory pulmonology and dedicated ambulatory teaching. Important features of the ambulatory block structure include separation of outpatient clinics from competing responsibilities, expansion of fellow pulmonary exposure, opportunities for deliberate practice, and faculty engagement in fellow education.
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Affiliation(s)
- Kathleen A. McAvoy
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Katherine A. Gielissen
- Grady Section, Division of General Internal Medicine, Emory School of Medicine, Atlanta, Georgia
| | - Jennifer D. Possick
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
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Prince LK, Y’Barbo BC, Nee R, Yuan CM. The peritoneal dialysis orders objective structured clinical examination (OSCE): A formative assessment for nephrology fellows. Perit Dial Int 2021; 41:472-479. [DOI: 10.1177/08968608211000542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Peritoneal dialysis (PD) management is a fundamental nephrology skill, especially with the recent emphasis on home dialysis. We report a prospective multicentre cohort study of a formative objective structured clinical examination (OSCE) assessing competence in managing PD-associated bacterial peritonitis, using the unified model of construct validity. Methods: The OSCE was developed by the principal investigators and reviewed by two subject matter experts. The test committee (eight nephrologists and one PD nurse) assessed test item difficulty/relevance and determined passing score. There were 22 test items (7 evidence-based/standard-of-care questions). Passing score was 16/22 (73%). No item had median relevance less than ‘important’, and all were easy to medium difficulty. Content validity index was 0.91. Preliminary validation (16 board-certified volunteers): mean score was 19 ± 2, with 94% (15/16) passing. Kappa = 0.85 [95% confidence interval (CI) 0.77–0.94]. Cronbach’s α = 0.70. Results: Eighty-seven fellows (16 programmes) were tested; 67% passed. Fellows scored significantly less than validators: 17 ± 3 versus 19 ± 2, p < 0.001 [95% CI 1.2–3.6]. Eighty-six per cent of evidence-based/standard-of-care questions were answered correctly by validators versus 54% by fellows; p < 0.001. Ninety-three per cent of fellows recognized that sufficient criteria were present to diagnose peritonitis, but only 17% correctly indicated all three. Seventy-seven per cent recognized peritonitis-associated ultrafiltration failure, but only 17% prescribed 21 days of antibiotic treatment for gram-negative peritonitis. Eighty-five per cent of fellows surveyed agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Second-year in-training examination and OSCE scores were positively correlated (Pearson’s r = 0.57, p < 0.00). Conclusions: The OSCE may be used to formatively assess fellow proficiency in managing PD-associated peritonitis.
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Affiliation(s)
- Lisa K Prince
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Brian C Y’Barbo
- Department of Medicine, Brooke Army Medical Center, San Antonio, TX, USA
| | - Robert Nee
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christina M Yuan
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Plotkin JB, Xu EJ, Fine DM, Knicely DH, Sperati CJ, Sozio SM. A Night Float System in Nephrology Fellowship: A Mixed Methods Evaluation. KIDNEY360 2020; 1:631-639. [PMID: 35372934 PMCID: PMC8815554 DOI: 10.34067/kid.0001572020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/06/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Johns Hopkins was an early adopter of an in-house nephrology fellowship night float to improve work-life balance. Our study aimed to elucidate attitudes to guide fellowship structuring. METHODS We performed a mixed-methods study surveying Johns Hopkins fellows, alumni, and faculty and conducting one focus group of current fellows. Surveys were developed through literature review, queried on a five-point Likert scale, and analyzed with t and ANOVA tests. The focus group transcript was analyzed by two independent reviewers. RESULTS Survey response rates were 14 (100%) fellows, 32 (91%) alumni, and 17 (94%) faculty. All groups felt quality of patient care was good to excellent with no significant differences among groups (range of means [SD], 4.1 [0.7]-4.6 [0.7]; P=0.12), although fellows had a statistically significantly more positive view than faculty on autonomy (4.6 [0.5] versus 4.1 [0.3]; P=0.006). Fellows perceived a positive effect across all domains of night float on the day team experience (range, 4.2 [0.8]-4.6 [0.6]; P<0.001 compared with neutral effect). Focus group themes included patient care, care continuity, professional development, wellness, and structural components. One fellow said, "…my bias is that every program would switch to a night float system if they could." All groups were satisfied with night float with 4.7 [0.5], 4.2 [0.8], and 4.0 [0.9] for fellows, faculty, and alumni, respectively; fellows were most enthusiastic (P=0.03). All three groups preferred night float, and fellows did so unanimously. CONCLUSIONS Night float was well liked and enhanced the perceived daytime fellow experience. Alumni and faculty were positive about night float, although less so, possibly due to concerns for adequate preparation to handle overnight calls after graduation. Night float implementation at other nephrology programs should be considered based on program resources; such changes should be assessed by similar methods.
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Affiliation(s)
- Jennifer B. Plotkin
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Eric J. Xu
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Derek M. Fine
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daphne H. Knicely
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - C. John Sperati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen M. Sozio
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
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4
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Agha IA, Mahbod D, Ilahe A, Nadella R, Nangia SK, Rosenblatt SG, Saigal N, Chimata YP. Current State and Future of Private Practice Nephrology in the United States. Adv Chronic Kidney Dis 2020; 27:356-360.e1. [PMID: 33131650 DOI: 10.1053/j.ackd.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/11/2022]
Abstract
Chronic kidney disease remains highly prevalent and exerts a heavy economic burden. The practice of nephrology has come a long way in managing this disease, though there remains room for improvement. The private domain, where more than half of the adult nephrology workforce operates, faces serious challenges. Interest has decreased in the field, leading to diminished recruitment. There has been a reduction in both reimbursement rates and revenues. We discuss the current state of private practice nephrology and strategies to reinvigorate our discipline. There needs to be a focus on preparing fellows during training not only for academic careers, but also for effective functioning in the environment of private practice and development of pathways for growth. We believe that private practice nephrology must expand its frontiers to be fulfilling professionally, challenging academically, and successful financially. The United States government has recently announced the Advancing American Kidney Health Executive Order which seeks to prioritize optimal treatments for patients with kidney disease. We are optimistic that there is a renaissance afoot in nephrology and that our field is in the process of rediscovering itself, with its best days yet to come.
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Yuan CM, Little DJ, Marks ES, Watson MA, Raghavan R, Nee R. The Electronic Medical Record and Nephrology Fellowship Education in the United States: An Opinion Survey. Clin J Am Soc Nephrol 2020; 15:949-956. [PMID: 32576553 PMCID: PMC7341781 DOI: 10.2215/cjn.14191119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/29/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES An unintended consequence of electronic medical record use in the United States is the potential effect on graduate physician training. We assessed educational burdens and benefits of electronic medical record use on United States nephrology fellows by means of a survey. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used an anonymous online opinion survey of all United States nephrology program directors (n=148), their faculty, and fellows. Program directors forwarded survey links to fellows and clinical faculty, indicating to how many they forwarded the link. The three surveys had parallel questions to permit comparisons. RESULTS Twenty-two percent of program directors (n=33) forwarded surveys to faculty (n=387) and fellows (n=216; 26% of United States nephrology fellows). Faculty and fellow response rates were 25% and 33%, respectively; 51% of fellows agreed/strongly agreed that the electronic medical record contributed positively to their education. Perceived positive effects included access flexibility and ease of obtaining laboratory/radiology results. Negative effects included copy-forward errors and excessive, irrelevant documentation. Electronic medical record function was reported to be slow, disrupted, or completely lost monthly or more by >40%, and these were significantly less likely to agree that the electronic medical record contributed positively to their education. Electronic medical record completion time demands contributed to fellow reluctance to do procedures (52%), participate in conferences (57%), prolong patient interactions (74%), and do patient-directed reading (55%). Sixty-five percent of fellows reported often/sometimes exceeding work-hours limits due to documentation time demands; 85% of faculty reported often/sometimes observing copy-forward errors. Limitations include potential nonresponse and social desirability bias. CONCLUSIONS Respondents reported that the electronic medical record enhances fellow education with efficient and geographically flexible patient data access, but the time demands of data and order entry reduce engagement in educational activities, contribute to work-hours violations, and diminish direct patient interactions.
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Affiliation(s)
- Christina M Yuan
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dustin J Little
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Eric S Marks
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Maura A Watson
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Rajeev Raghavan
- Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Robert Nee
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, Maryland
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A nationwide survey on clinical practice patterns and bleeding complications of percutaneous native kidney biopsy in Japan. Clin Exp Nephrol 2020; 24:389-401. [PMID: 32189101 PMCID: PMC7174253 DOI: 10.1007/s10157-020-01869-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/01/2020] [Indexed: 12/29/2022]
Abstract
Background Practice patterns and bleeding complications of percutaneous native kidney biopsy (PNKB) have not recently been investigated and the Japanese Society of Nephrology performed a nationwide questionnaire survey in 2018. Methods The survey consisted of nine sections about PNKB: (1) general indications; (2) indications for high-risk patients; (3) informed consent; (4) pre-biopsy evaluation; (5) procedures; (6) sedation; (7) post-biopsy hemostasis, bed rest, and examinations; (8) bleeding complications; and (9) specimen processing. A supplementary survey examined bleeding requiring transcatheter arterial embolization (TAE). Results Overall, 220 directors of facilities (nephrology facility [NF], 168; pediatric nephrology facility [PF], 52) completed the survey. Indications, procedures, and monitoring protocols varied across facilities. Median lengths of hospital stay were 5 days in NFs and 6 days in PFs. Gauge 14, 16, 18 needles were used in 5%, 56%, 33% in NFs and 0%, 63%, 64% in PFs. Mean limits of needle passes were 5 in NFs and 4 in PFs. The bed rest period was 16–24 h in 60% of NFs and 65% of PFs. Based on 17,342 PNKBs, incidence rates of macroscopic hematuria, erythrocyte transfusion, and TAE were 3.1% (NF, 2.8%; PF, 6.2%), 0.7% (NF, 0.8%; PF, 0%), and 0.2% (NF, 0.2%; PF, 0.06%), respectively. Forty-six percent of facilities processed specimens all for light microscopy, immunofluorescence, and electron microscopy, and 21% processed for light microscopy only. Timing of bleeding requiring TAE varied among PNKB cases. Conclusion Wide variations in practice patterns of PNKB existed among facilities, while PNKBs were performed as safely as previously reported. Electronic supplementary material The online version of this article (10.1007/s10157-020-01869-w) contains supplementary material, which is available to authorized users.
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Prince LK, Nee R, Yuan CM. The Acute Dialysis Orders Objective Structured Clinical Examination (OSCE): Fellow Performance on a Formative Assessment of Acute Kidney Replacement Therapy Competence. Clin J Am Soc Nephrol 2019; 14:1346-1354. [PMID: 31409597 PMCID: PMC6730513 DOI: 10.2215/cjn.02900319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/29/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute kidney replacement therapy (KRT) prescription is a critical nephrology skill. We administered a formative objective structured clinical examination (OSCE) to nephrology fellows to assess acute KRT medical knowledge, patient care, and systems-based practice competencies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Prospective cohort study of an educational test using the unified model of construct validity. We tested 117 fellows: 25 (four programs) in 2016 and 92 (15 programs) in 2017; 51 first-year and 66 second-year fellows. Using institutional protocols and order sets, fellows wrote orders and answered open-ended questions on a three-scenario OSCE, previously validated by board-certified, practicing clinical nephrologists. Outcomes were overall and scenario pass percentage and score; percent correctly answering predetermined, evidence-based questions; second-year score correlation with in-training examination score; and satisfaction survey. RESULTS A total of 76% passed scenario 1 (acute continuous RRT): 92% prescribed a ≥20 ml/kg per hour effluent dose; 63% estimated clearance as effluent volume. Forty-two percent passed scenario 2 (maintenance dialysis initiation); 75% correctly prescribed 3-4 mEq/L K+ dialysate and 12% identified the two absolute, urgent indications for maintenance dialysis initiation (uremic encephalopathy and pericarditis). Six percent passed scenario 3 (acute life-threatening hyperkalemia); 20% checked for rebound hyperkalemia with two separate blood draws. Eighty-three percent correctly withheld intravenous sodium bicarbonate for acute hyperkalemia in a nonacidotic, volume-overloaded patient on maintenance dialysis, and 32% passed overall. Second-year versus first-year fellow overall score was 44.4±4 versus 42.7±5 (one-tailed P=0.02), with 39% versus 24% passing (P=0.08). Second-year in-training examination and OSCE scores were not significantly correlated (r=0.15; P=0.26). Seventy-seven percent of fellows agreed the OSCE was useful in assessing "proficiency in ordering" acute KRT. Limitations include lack of a validated criterion test, and unfamiliarity with open-ended question format. CONCLUSIONS The OSCE can provide quantitative data for formative Accreditation Council for Graduate Medical Education competency assessments and identify opportunities for dialysis curriculum development. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_08_CJASNPodcast_19_09_.mp3.
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Affiliation(s)
- Lisa K Prince
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Robert Nee
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Christina M Yuan
- Nephrology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
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Yuan CM, Oliver JD, Little DJ, Narayan R, Prince LK, Raghavan R, Nee R. Survey of non-tunneled temporary hemodialysis catheter clinical practice and training. J Vasc Access 2018; 20:507-515. [PMID: 30590997 DOI: 10.1177/1129729818820231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Nephrologists are placing fewer non-tunneled temporary hemodialysis catheters. Requiring competence for nephrology fellow graduation is controversial. METHODS Anonymous, online survey of all graduates from a single, military nephrology training program (n = 81; 1985-2017) and all US Nephrology program directors (n = 150). RESULTS Graduate response and completion rates were 59% and 100%, respectively; 93% agreed they had been adequately trained; 58% (26/45) place non-tunneled temporary hemodialysis catheters, independent of academic practice or time in practice, but 12/26 did ⩽5/year and 23/26 referred some or all. The most common reason for continuing non-tunneled temporary hemodialysis catheter placement was that it is an essential emergency procedure (92%). The single most significant barrier was time to do the procedure (49%). Program director response and completion rates were 50% and 79%, respectively. The single most important barrier to fellow competence was busyness of the service (36%), followed by disinterest (21%); 55% believed that non-tunneled temporary hemodialysis catheter insertion competence should be required, with 81% indicating it was an essential emergency procedure. The majority of graduates and program directors agreed that simulation training was valuable; 76% of programs employ simulation. Graduates who had simulation training and program directors with ⩽20 years of practice were significantly more likely to agree that simulation training was necessary. CONCLUSION Of the graduate respondents from a single training program, 58% continue to place non-tunneled temporary hemodialysis catheters; 55% of program directors believe non-tunneled temporary hemodialysis catheter procedural competence should be required. Graduates who had non-tunneled temporary hemodialysis catheter simulation training and younger program directors consider simulation training necessary. These findings should be considered in the discussion of non-tunneled temporary hemodialysis catheter curriculum requirements.
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Affiliation(s)
- Christina M Yuan
- 1 Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - James D Oliver
- 1 Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Dustin J Little
- 1 Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rajeev Narayan
- 2 San Antonio Kidney Disease Center Physicians Group, San Antonio, TX, USA
| | - Lisa K Prince
- 1 Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rajeev Raghavan
- 3 Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX, USA
| | - Robert Nee
- 1 Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Yuan CM, Nee R, Little DJ, Narayan R, Childs JM, Prince LK, Raghavan R, Oliver JD. Survey of Kidney Biopsy Clinical Practice and Training in the United States. Clin J Am Soc Nephrol 2018; 13:718-725. [PMID: 29669819 PMCID: PMC5968891 DOI: 10.2215/cjn.13471217] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/13/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Practicing clinical nephrologists are performing fewer diagnostic kidney biopsies. Requiring biopsy procedural competence for graduating nephrology fellows is controversial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS An anonymous, on-line survey of all Walter Reed training program graduates (n=82; 1985-2017) and all United States nephrology program directors (n=149; August to October of 2017), regarding kidney biopsy practice and training, was undertaken. RESULTS Walter Reed graduates' response and completion rates were 71% and 98%, respectively. The majority felt adequately trained in native kidney biopsy (83%), transplant biopsy (82%), and tissue interpretation (78%), with no difference for ≤10 versus >10 practice years. Thirty-five percent continued to perform biopsies (13% did ≥10 native biopsies/year); 93% referred at least some biopsies. The most common barriers to performing biopsy were logistics (81%) and time (74%). Program director response and completion rates were 60% and 77%. Seventy-two percent cited ≥1 barrier to fellow competence. The most common barriers were logistics (45%), time (45%), and likelihood that biopsy would not be performed postgraduation (41%). Fifty-one percent indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications. Program directors citing ≥1 barrier or whose fellows did <50 native biopsies/year in total were more likely to think that procedural competence should not be required versus those citing no barriers (P=0.02), or whose fellows performed ≥50 biopsies (P<0.01). CONCLUSIONS Almost two-thirds of graduate respondents from a single military training program no longer perform biopsy, and 51% of responding nephrology program directors indicated that biopsy procedural competence should not be required. These findings should inform discussion of kidney biopsy curriculum requirements.
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Affiliation(s)
| | | | | | - Rajeev Narayan
- San Antonio Kidney Disease Center, San Antonio, Texas; and
| | - John M. Childs
- Department of Pathology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Rajeev Raghavan
- Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
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Prince LK, Campbell RC, Gao SW, Kendrick J, Lebrun CJ, Little DJ, Mahoney DL, Maursetter LA, Nee R, Saddler M, Watson MA, Yuan CM. The dialysis orders objective structured clinical examination (OSCE): a formative assessment for nephrology fellows. Clin Kidney J 2018; 11:149-155. [PMID: 29644053 PMCID: PMC5887504 DOI: 10.1093/ckj/sfx082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/21/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis. METHODS The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than 'important'. The content validity index was 0.91. Ninety-five percent of positive-point items were easy-medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46-51], κ = 0.68 (95% CI 0.59-0.77), Cronbach's α = 0.84. RESULTS We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43-45); 36% passed the test. Fellows scored significantly less than validators (P < 0.001). Of evidence-based questions, 72% were answered correctly by validators and 54% by fellows (P = 0.018). Fellows and validators scored least well on the acute hyperkalemia question. In self-assessing proficiency, 71% of fellows surveyed agreed or strongly agreed that the OSCE was useful. CONCLUSIONS The OSCE may be used to formatively assess fellow proficiency in three common areas of acute dialysis practice. Further validation studies are in progress.
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Affiliation(s)
- Lisa K Prince
- Nephrology Division, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ruth C Campbell
- Nephrology Division, Medical University of South Carolina, Charleston, SC, USA
| | - Sam W Gao
- Nephrology Division, Portsmouth Naval Medical Center, Portsmouth, VA, USA
| | - Jessica Kendrick
- Department of Renal Diseases and Hypertension, University of Colorado, Denver, CO, USA
| | - Christopher J Lebrun
- Department of Internal Medicine, Baptist Memorial Hospital, Golden Triangle, Columbus, MS, USA
| | - Dustin J Little
- Nephrology Division, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | - Robert Nee
- Nephrology Division, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Mark Saddler
- Nephrology Associates, Mercy Regional Medical Center, Durango, CO, USA
| | - Maura A Watson
- Nephrology Division, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christina M Yuan
- Nephrology Division, Walter Reed National Military Medical Center, Bethesda, MD, USA
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11
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Affiliation(s)
- Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Melamed ML, Campbell KN, Nickolas TL. Resizing Nephrology Training Programs: A Call to Action. Clin J Am Soc Nephrol 2017; 12:1718-1720. [PMID: 28838989 PMCID: PMC5628718 DOI: 10.2215/cjn.04740517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Michal L. Melamed
- Nephrology Fellowship Training Program Director, Albert Einstein College of Medicine/Montefiore Medical Center, Montefore Medical Center, Bronx, New York
| | - Kirk N. Campbell
- Nephrology Fellowship Training Program Director, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Thomas L. Nickolas
- Nephrology Fellowship Training Program Director, Columbia University Medical Center, New York, New York
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13
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Kumar NL, Perencevich ML, Trier JS. Perceptions of the Inpatient Training Experience: A Nationwide Survey of Gastroenterology Program Directors and Fellows. Dig Dis Sci 2017; 62:2631-2647. [PMID: 28815353 DOI: 10.1007/s10620-017-4711-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/07/2017] [Indexed: 12/09/2022]
Abstract
BACKGROUND Inpatient training is a key component of gastroenterology (GI) fellowship programs nationwide, yet little is known about perceptions of the inpatient training experience. AIM To compare the content, objectives and quality of the inpatient training experience as perceived by program directors (PD) and fellows in US ACGME-accredited GI fellowship programs. METHODS We conducted a nationwide, online-based survey of GI PDs and fellows at the conclusion of the 2016 academic year. We queried participants about (1) the current models of inpatient training, (2) the content, objectives, and quality of the inpatient training experience, and (3) the frequency and quality of educational activities on the inpatient service. We analyzed five-point Likert items and rank assessments as continuous variables by an independent t test and compared proportions using the Chi-square test. RESULTS Survey response rate was 48.4% (75/155) for PDs and a total of 194 fellows completed the survey, with both groups reporting the general GI consult team (>90%) as the primary model of inpatient training. PDs and fellows agreed on the ranking of all queried responsibilities of the inpatient fellow to develop during the inpatient service. However, fellows indicated that attendings spent less time teaching and provided less formal feedback than that perceived by PDs (p < 0.0001). PDs rated the overall quality of the inpatient training experience (p < 0.0001) and education on the wards (p = 0.0003) as better than overall ratings by fellows. CONCLUSION Although GI fellows and PDs agree on the importance of specific fellow responsibilities on the inpatient service, fellows report experiencing less teaching and feedback from attendings than that perceived by PDs. Committing more time to education and assessment may improve fellows' perceptions of the inpatient training experience.
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Affiliation(s)
- Navin L Kumar
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Molly L Perencevich
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Jerry S Trier
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
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Rope RW, Pivert KA, Parker MG, Sozio SM, Merell SB. Education in Nephrology Fellowship: A Survey-Based Needs Assessment. J Am Soc Nephrol 2017; 28:1983-1990. [PMID: 28428332 DOI: 10.1681/asn.2016101061] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Robert W Rope
- Division of Nephrology, Stanford University School of Medicine, Stanford, California;
| | | | - Mark G Parker
- Division of Nephrology, Maine Medical Center and Tufts University School of Medicine, Portland, Maine
| | - Stephen M Sozio
- Division of Nephrology and.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Sylvia Bereknyei Merell
- Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, California
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