Lessons learned from the ASN Renal Educator Listserv and survey

The times they are K+-changin': bringing the potassium curriculum out of the 20th century

PURPOSE OF REVIEW

Although most of the current medical education literature has focused on teaching strategies, little attention has been devoted to selecting appropriate course content. Despite elegant descriptions of physiologic mechanisms in recent decades, medical school curricula and students continue to rely on outdated textbooks and certification examination study aids composed to fit an antiquated exam blueprint.

RECENT FINDINGS

Advances in our understanding of potassium physiology offer multiple examples of key concepts that deserve to be included in the modern-day renal physiology curriculum, including the relationship of potassium to blood pressure and the potassium 'switch', the aldosterone paradox, and novel pharmacologic agents that target dietary potassium absorption and potassium handling in the kidney.

SUMMARY

Key advances in our understanding and application of renal physiology to patient care have not been readily integrated into the nephrology curriculum of medical students. Difficult questions remain regarding when new concepts are sufficiently established to be introduced to medical students in the preclinical years.

The evolution of social media in nephrology education: A mini-review

Social media is defined as "a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, that allow the creation and exchange of user-generated content". Social media can be used in medical education to enhance knowledge sharing among peer groups and the public in general. The internet revolutionized learning by allowing easier dissemination of knowledge that did not depend on printing and physical distribution of books, journals, or magazines. According to a report from 2018, 95% of students have access to smartphones and 45% are online at any given time. Social media platforms are powerful tools to spread knowledge by the way of stories, videos, and educational games. Both formal and informal learning can be achieved with the use of social media. The microblogging website Twitter has become a popular social media platform by many in medical education including the nephrology community. Twitter, for example, is used to build communities, discuss journal articles, inform the community of conferences, share infographics and visual abstracts of original research work. As an example, it can be difficult for women in nephrology to connect and travel to make a physical presence. The use of social media allows women to connect via webinars and Women in Nephrology (WIN) India live Twitter chats. Thus, social media can help facilitate networking and collaboration with nephrologists all over the world. Social media has limitations as well. Insensitive posts can have a detrimental effect on one's career. A survey has shown that increased use of social media can contribute to addiction, anxiety, diminished self-esteem, and even depression. Hence, in order to effectively use social media to contribute positively to one's career, we recommend considering the positive and negative aspects of social media.This review will discuss the various social media platforms and how they have been applied to nephrology education.

What's Old Is New Again: Harnessing the Power of Original Experiments to Learn Renal Physiology

Although medical schools across the United States have updated their curricula to incorporate active learning techniques, there has been little discussion on the nature of the content presented to students. Here, we share detailed examples of our experience in using original experiments to lay the groundwork for foundational concepts in renal physiology and pathophysiology. We believe that this approach offers distinct advantages over standard case-based teaching by (1) starting with simple concepts, (2) analyzing memorable visuals, (3) increasing graphical literacy, (4) translating observations to "rules," (5) encouraging critical thinking, and (6) providing historical perspective to the study of medicine. Although we developed this content for medical students, we have found that many of these lessons are also appropriate as foundational concepts for residents and fellows and serve as an excellent springboard for increasingly complex discussions of clinical applications of physiology. The use of original experiments for teaching and learning in renal physiology harnesses skills in critical thinking and provides a solid foundation that will help learners with subsequent case-based learning in the preclerkship curriculum and in the clinical arena.

Teaching nephrology as part of a degree in medicine

The teaching of nephrology as part of a degree in medicine is potentially one of the most decisive factors when choosing a speciality. Until now, however, we have not had an overview of the teaching of nephrology in Spain. We have integrated information available in public databases with a survey and personal interviews with those responsible for teaching in Spanish medical faculties. In 2019, there were 44 universities offering a medicine degree in Spain, in 16 Autonomous Communities (34 of which were public and 10 private). For learning purposes, students have a number of hospital beds ranging from 0.2 to 4.7, and there are Autonomous Communities that have a higher proportion of students per inhabitant or per physician, such as Madrid or the Community of Navarra. In 16 universities there are tenured teaching staff (professors and lecturers), in eight contracted medical lecturers, and in two assistant lecturers. In 21 medical faculties, theoretical and practical nephrology is taught by associate lecturers. The subject is taught between the third and fifth years of the degree, the median being the fourth year. It is usually integrated with another subject and only in the University of Navarra is it an independent subject, with three credits. The total number of hours devoted to theoretical teaching (both theoretical classes and seminars) is highly variable and ranges from 11 to 35, with a median of 17.5. Variability is observed in both the number of theoretical topics (range 11-31) and seminars (range 0-9). Among the faculties that teach seminars, the ratio of theoretical topics to seminars ranges from 1.6 to 18. Most faculties evaluate clinical practices with various modalities and percentage of assessment. Knowledge is mostly assessed by a multiple choice exam. In conclusion, there is a high level of variability in the curriculum for the teaching of nephrology as part of a degree in medicine in Spain. Teaching staff who are tenured or who have a stable affiliation with universities make up just 23% of the total and, in many faculties, teaching depends exclusively on associate professors.

"To Be, or Not to Be" a Nephrologist: Students' Dilemma and a Strategy for the Field

The attractiveness of a career in nephrology has diminished over the past decades, leading to global concerns about the future of the specialty's workforce. The reasons physicians choose (and do not choose) a career in the field must be identified in order to boost recruitment of new nephrologists. In this article, a multilevel strategy is proposed to deal with the declining interest in the specialty: (1) increasing contact and providing early exposure to nephrology; (2) promoting mentoring and role models in medical schools; (3) improving the experience of trainees and medical students; (4) incorporating procedural skills and combined fellowship training with critical care in nephrology; (5) facilitating exchanges between trainees and young and senior nephrologists; (6) adopting an active approach to identify reasons for dissatisfaction, reduce burnout, and encourage a suitable work-life balance among nephrologists; (7) increasing remuneration; and (8) incentivizing advances in the field. Finally, a positive perspective for nephrology is presented to the next generation.

[Teaching nephrology as part of a degree in medicine]

The teaching of nephrology as part of a degree in medicine is potentially one of the most decisive factors when choosing a speciality. Until now, however, we have not had an overview of the teaching of nephrology in Spain. We have integrated information available in public databases with a survey and personal interviews with those responsible for teaching in Spanish medical faculties. In 2019, there were 44 universities offering a medicine degree in Spain, in 16 Autonomous Communities (34 of which were public and 10 private). For learning purposes, students have a number of hospital beds ranging from 0.2 to 4.7, and there are Autonomous Communities that have a higher proportion of students per inhabitant or per physician, such as Madrid or the Community of Navarra. In 16 universities there are tenured teaching staff (professors and lecturers), in 8 contracted medical lecturers, and in 2 assistant lecturers. In 21 medical faculties, theoretical and practical nephrology is taught by associate lecturers. The subject is taught between the third and fifth years of the degree, the median being the fourth year. It is usually integrated with another subject and only in the University of Navarra is it an independent subject, with 3 credits. The total number of hours devoted to theoretical teaching (both theoretical classes and seminars) is highly variable and ranges from 11 to 35, with a median of 17.5. Variability is observed in both the number of theoretical subjects (range 11 to 31) and seminars (range 0 to 9). Among the faculties that teach seminars, the ratio of theoretical topics to seminars ranges from 1.6 to 18. Most faculties evaluate clinical practices with various modalities and percentage of assessment. Knowledge is mostly assessed by a multiple choice exam. In conclusion, there is a high level of variability in the curriculum for the teaching of nephrology as part of a degree in medicine in Spain. Teaching staff who are tenured or who have a stable affiliation with universities make up just 23% of the total and, in many faculties, teaching depends exclusively on associate professors.

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.

Faculty Use of Active Learning in Postgraduate Nephrology Education: A Mixed-Methods Study

Background

Active learning is an effective instructional tool in medical education. However, its integration by nephrology faculty remains limited despite residents’ declining interest in nephrology.

Study Design

A sequential explanatory mixed-methods study design was used to explore nephrology faculty understanding of difficult teaching topics and active learning integration using the theory of planned behavior as theoretical framework.

Setting & Participants

Nephrology faculty at 6 residency sites in Singapore were recruited.

Methodology

A 28-item questionnaire was administered to conveniently sampled faculty followed by 1-to-1 semi-structured interviews of a purposively sampled subset.

Analytical Approach

Quantitative data were analyzed using descriptive and regression statistics. Qualitative data were analyzed using thematic analysis in line with the theory of planned behavior constructs (attitude, subjective norm, perceived behavioral control, intention, and behavior).

Results

49 of 82 invited faculty responded, with 49% and 42% perceiving self-directed learning and interactive lectures, respectively, as active learning formats. Fluid, electrolyte, and acid-base disturbances; transplantation immunology; glomerulonephritis; and hemodialysis adequacy were cited as difficult topics by 75%, 63%, 45%, and 31% of responders, respectively. Only 55% reported integrating active learning formats when teaching difficult topics. Faculty in leadership roles and teaching difficult topics more regularly were more likely to adopt active learning formats. Multivariable logistic regression analysis showed that faculty attitude strongly and significantly predicted active learning intention. Thematic analysis identified 4 themes: active learning competence, barriers and challenges, environmental influence, and self-identity. Self-identity, defined as values developed from past behavior and experience, emerged as an important contributor to active learning adoption outside the theory of planned behavior framework.

Limitations

Sampling, context, and measurement biases may affect study reliability and generalizability.

Conclusions

Nephrology faculty lack active learning competence and face cognitive challenges when teaching difficult topics. Faculty teaching experience significantly influenced active learning adoption. Our findings build on the theoretical understanding of faculty instructional innovation adoption and can inform nephrology faculty development initiatives.

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.

Nephrology education for medical students: a narrative review

BACKGROUND

Strategies used to teach nephrology to medical students are not well studied. This study assesses the published literature on medical student education in nephrology.

METHODS

A review of the published literature on nephrology education for medical students was conducted on two major online search engines (PubMed and ERIC). In addition, references of the manuscripts discovered in these searches were reviewed. The empirical studies were categorized by subject within nephrology and research design.

RESULTS

We found 26 original studies in which a method of teaching nephrology to medical students was described. The studies dated from 1977 to 2015. The focus of these nephrology teaching experiences was as follows: anatomy (6.5%), physiology (22.6%), pathophysiology (29.0%), pathology (6.5%), treatment (25.8%), and general nephrology (9.7%). The studies were also categorized into various types of research design. 6.9% had either no assessment of the educational experience or had a description too vague to categorize it; 3.4% involved a survey about the existing educational approach before a curriculum change was implemented; 55.2% used surveys or tests after an educational course was carried out; 10.3% sought feedback from students before and after the educational experience; 13.8% were case studies; and 10.3% included a randomized controlled trial. The randomized controlled trials involved teaching techniques focused on the pathophysiology of renal disease.

CONCLUSIONS

Rigor was lacking in most empirical studies on medical student education in nephrology. Well-designed randomized controlled studies are needed to accurately assess the effectiveness of the educational techniques introduced into medical school curricula.

Teaching renal physiology in the 21st century: focus on acid-base physiology

A thorough understanding of renal physiology, and in particular acid–base physiology, is essential for an understanding of nephrology. Difficulties in both teaching and learning this material are major impediments to attracting medical trainees into nephrology. Approaches to teaching renal physiology include collaborative learning, computer-based learning and laboratory-based learning. Computer-based learning applications are becoming increasingly popular and can be useful, but are most successful when they incorporate interactive components. Students also note that the presence of a live instructor remains desirable. Some concepts of renal and in particular acid–base physiology can be taught using structured self-experimentation, a practice with a long tradition that possibly should be revitalized.

Exploring student preferences with a Q-sort: the development of an individualized renal physiology curriculum

Medical education reform is underway, but the optimal course for change has yet to be seen. While planning for the redesign of a renal physiology course at the Duke School of Medicine, the authors used a Q-sort survey to assess students' attitudes and learning preferences to inform curricular change. The authors invited first-year medical students at the Duke School of Medicine to take a Q-sort survey on the first day of renal physiology. Students prioritized statements related to their understanding of renal physiology, learning preferences, preferred course characteristics, perceived clinical relevance of renal physiology, and interest in nephrology as a career. By-person factor analysis was performed using the centroid method. Three dominant factors were strongly defined by learning preferences: "readers" prefer using notes, a textbook, and avoid lectures; "social-auditory learners" prefer attending lectures, interactivity, and working with peers; and "visual learners" prefer studying images, diagrams, and viewing materials online. A smaller, fourth factor represented a small group of students with a strong predisposition against renal physiology and nephrology. In conclusion, the Q-sort survey identified and then described in detail the dominant viewpoints of our students. Learning style preferences better classified first-year students rather than any of the other domains. A more individualized curriculum would simultaneously cater to the different types of learners in the classroom.

Medical student web-based formative assessment tool for renal pathology

BACKGROUND

Web-based formative assessment tools have become widely recognized in medical education as valuable resources for self-directed learning.

OBJECTIVES

To explore the educational value of formative assessment using online quizzes for kidney pathology learning in our renal pathophysiology course.

METHODS

Students were given unrestricted and optional access to quizzes. Performance on quizzed and non-quizzed materials of those who used ('quizzers') and did not use the tool ('non-quizzers') was compared. Frequency of tool usage was analyzed and satisfaction surveys were utilized at the end of the course.

RESULTS

In total, 82.6% of the students used quizzes. The greatest usage was observed on the day before the final exam. Students repeated interactive and more challenging quizzes more often. Average means between final exam scores for quizzed and unrelated materials were almost equal for 'quizzers' and 'non-quizzers', but 'quizzers' performed statistically better than 'non-quizzers' on both, quizzed (p=0.001) and non-quizzed (p=0.024) topics. In total, 89% of surveyed students thought quizzes improved their learning experience in this course.

CONCLUSIONS

Our new computer-assisted learning tool is popular, and although its use can predict the final exam outcome, it does not provide strong evidence for direct improvement in academic performance. Students who chose to use quizzes did well on all aspects of the final exam and most commonly used quizzes to practice for final exam. Our efforts to revitalize the course material and promote learning by adding interactive online formative assessments improved students' learning experience overall.

Recruiting the next generation of nephrologists

The nephrology physician workforce substantially expanded during the past decade, as did the number of fellowship training positions. However, the number of U.S. medical graduates choosing nephrology careers has declined precipitously. Although workforce diversity has improved, the gains are modest. Leadership in kidney disease research and innovation is threatened by significant disincentives to the pursuit of research track careers. Meanwhile, various factors challenge reliable predictions of physician workforce demand: marked growth of the CKD and ESRD populations, shifting health care economics and access, restricted opportunities for international medical graduates, expansion of advanced practitioner utilization, and aging of the contemporary practicing physician cohort. Changing demographics and cultural shifts, including perceptions of work-life balance and quality of life, increasingly influence medical student and resident career choices. Negative student and resident attitudes toward core nephrology educational experiences and perceptions of nephrology careers are disquieting. The American Society of Nephrology has initiated a series of programs aimed at renewing interest among students and residents in nephrology careers and research training and continuing to improve the diversity of the nephrology workforce, both critical to ensuring there will be enough nephrologists to care for a growing kidney disease population.

Novel educational approaches to enhance learning and interest in nephrology

The number of U.S. medical graduates pursuing careers in nephrology has declined over the last several years. Some of the proposed reasons for this declining interest include difficult-to-understand or unstimulating kidney pathophysiology courses in medical school; disheartening inpatient elective experiences; and few opportunities to experience the other aspects of nephrology careers such as outpatient nephrology clinics, outpatient dialysis, and kidney transplantation. Novel and alternative educational approaches should be considered by the nephrology training community to enhance the understanding of nephrology from medical school to fellowship training. Newer teaching methods and styles should also be incorporated to adapt to today's learner. These innovative educational approaches may not only increase interest in nephrology careers, but they may also enhance and maintain interest during nephrology fellowship. In this article, we will review several educational approaches that may enhance teaching and learning in nephrology.