Adult Nephrology Fellowship Training in the United States: Trends and Issues
Mark E. Rosenberg
Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
Address correspondence to: Dr. Mark E. Rosenberg, Division of Renal Diseases and Hypertension, MMC 736, 516 Delaware Street S.E., Minneapolis, MN 55455. Phone: 612-624-9444; Fax: 612-626-3840; E-mail: rosen001{at}umn.edu
This article reviews trends and issues related to adult nephrologyfellowship education in the United States. The number of nephrologyfellowship programs and trainees has continued to increase slowlydespite limitations in funding of graduate medical education.The use of the Electronic Residency Application System has providedinformation for the first time on the number, demographics,and behavior of applicants that can be used as baseline datafor tracking trends in fellowship applications and for formulatingtraining policies. Issues that nephrology training programsface are discussed in this review: (1) A more stringent graduatemedical education regulatory environment, (2) the use of theNational Resident Matching Program to enhance the nephrologyfellowship applicant selection process, (3) future nephrologyworkforce shortages, and (4) the continued subspecializationof nephrology. By working together, nephrology fellowship programscan overcome barriers that are raised by these issues and improvethe fellowship training experience.
The objective of this article is to provide a summary of thetrends and issues in adult nephrology fellowship education inthe United States. Future decisions on education and policyissues require accurate information regarding the demographicsof nephrology trainees and programs. These data are availablefrom several national sources and are reviewed. With the useof an electronic application system, data are now availablefor the first time about the number and demographics of applicantsfor nephrology training. As the specialty of nephrology evolvesand the training environment changes, fellowship programs willhave to deal with a number of important matters. This articlediscusses issues that are related to accreditation, a formalmatch in nephrology, workforce needs, and further subspecialization.These issues are complex and often controversial but are raisedto foster constructive dialogue among the relevant constituencies.
Demographics of Nephrology Fellows and Programs
Demographic data were obtained from the National Graduate MedicalEducation Census obtained through Graduate Medical Education(GME) Track. This is an Internet-based system of the Associationof American Medical Colleges (AAMC) that is jointly sponsoredby the American Medical Association and the AAMC (http://www.aamc.org/programs/gmetrack/start.htm).Information from the GME Track survey is published in the annualmedical education issue of the Journal of the American MedicalAssociation (1–7). The most recent data are for the 2005to 2006 academic year and included 135 Accreditation Councilfor Graduate Medical Education (ACGME)-approved adult nephrologyfellowship programs (7). There were a total of 822 nephrologyfellows with 372 first-year fellows. The demographics of thefellows are shown in Table 1. The majority of fellows were eitherwhite (43.1%) or Asian (40.9%), with a relatively small numberof black or Hispanic fellows. The number of fellows who completedtraining in 2005 to 06 was 366.
Table 1. Demographics of adult nephrology training in the United States, 2005 (7)a
Trends in fellowship training are displayed in Figure 1 forthe academic years 1998 thru 2005. During this time, the numberof ACGME-approved fellowship programs increased from 127 to135, and the number of fellows increased from 635 to 822. Themajority of this growth has occurred since 2002. Because Medicarecaps for GME have remained frozen at 1996 levels, the sourcesof funding for this growth in fellowship numbers remains unclear.The percentage of international medical graduates (IMG) whoare enrolled in nephrology fellowship programs has decreasedfrom 1998 levels but has remained constant during the past fewyears (Figure 2).
Figure 1. Trends in adult nephrology fellowship training in the United States for 1998 to 2005. The total number of fellowship programs, fellows, and fellows who graduated from training programs are displayed.
Figure 2. The percentage of international medical graduates for each academic year is displayed.
Graduates of nephrology fellowship programs must take the AmericanBoard of Internal Medicine (ABIM) subspecialty certificationexamination in nephrology to become board certified. Table 2displays the number of first-time takers of this examinationalong with pass rates. As can be seen, pass rates were highand relatively stable during the past 3 yr.
Table 2. Pass rates for first-time takers of the ABIM subspecialty certification examination in nephrologya
Applications to Nephrology Fellowship Programs
The Electronic Residency Application System (ERAS) was usedfor the first time by adult nephrology fellowship programs forapplicants who were applying to start training on July 1, 2007.The transition to ERAS was voluntary, but the majority of nephrologyprograms participated. The main reasons for using ERAS wereto make the application process more standardized and to allowresidents more time to make appropriate career decisions. Inthe past before ERAS, interviews for nephrology fellowshipsusually took place 2 yr before starting a fellowship. With ERAS,programs received applications December 1, 2005, for the startdate of July 1, 2007. There was no uniform offer date or match,leaving many programs and applicants a short window of timeto interview and make selection decisions. Operationally, theapplication process using ERAS offered a number of advantages.All applicant documents were provided from one source, all applicationdata were automatically stored for comparison in one database,and tools were available to programs to facilitate review andevaluation of application material. The use of ERAS allowedinterested candidates to apply electronically to multiple programswith a single application.
There is no cost to nephrology fellowship programs for usingERAS. In fact, there is potential cost savings in the decreasedadministrative work that is involved in the handling of paperapplications. The cost to applicants is based on the numberof programs to which they apply. The cost for applying to upto 10 programs was $100; for 11 to 20 programs, the cost was$10 per program; for 21 to 30 programs, $15 each; and for 31or more programs, $25 each.
The use of ERAS provided for the first time national statisticsregarding the number, demographics, and behavior of applicants.These data are useful for future historical trending, analysisof workforce issues, and individual program comparison withnational statistics. As can be seen in Table 3, there were atotal of 757 applicants to nephrology, with US medical graduates(USMG) comprising 29.6% of applicants and IMG 70.4%. IMG appliedto a greater number of programs compared with USMG (35.9 versus16.9 programs per applicant), which is reflected in the totalnumber of applications received by each program. There werean estimated 372 first-year positions available, giving a ratioof 2.03 applicants per fellowship position. The number of IMGwho enrolled in fellowship programs has remained at approximately40% (Figure 2). If this trend continues, then >70% of IMGwho apply to nephrology fellowship programs may not be successfulin obtaining a fellowship position. Nephrology application dataare compared with that of other specialty programs in Table 4.As can be seen, nephrology ranked behind cardiology and hematologyand oncology in the total number of applications and was fourthin the number of applications from USMG. No data were availablefor gastroenterology which did not participate in ERAS but startedusing ERAS in December 2006.
Table 4. ERAS applications to all specialty fellowship programs for academic year 2007a
For the July 1, 2008, start date, 129 programs were listed asparticipating in ERAS (http://www.aamc.org/audienceeras.htm).Excluding military programs and programs in Puerto Rico, onlythree programs did not participate, for a participation rateof 97.7%. The ERAS Web site opened to applicants on July 1,2006, to allow them to begin working on their applications.On November 15, 2006, applicants could start selecting and applyingto specific programs. Applications became available to trainingprograms on December 1, 2006. ERAS is an application systemand does not mandate a uniform offer date to candidates or amatch. After much discussion, nephrology training programs havecommitted to the principle of a uniform interview season thatextends through January 31, 2007. During this time, programscan make offers to applicants but cannot demand a commitmentuntil February 1, 2007.
Accreditation Issues
Several new requirements that were instituted by the ACGME willbe challenging for fellowship training programs, departmentsof internal medicine, and sponsoring institutions. Funding forthe effort of the program director and key faculty is one challenge(8). The ACGME requires that the program director dedicate anaverage of 20 h/wk of his or her professional effort to thesubspecialty program, with sufficient time for administrationof the program. The program director must "receive institutionalsupport for that administrative time." Because this institutionalsupport is being mandated by the ACGME, it is critical thatfellowship programs work with their internal medicine departmentsand institutions to secure this funding.
In addition to the program director, each program must havekey clinical faculty (KCF) who on average dedicate 10 h/wk throughoutthe year to the training program. For programs with more thanfive fellows, a ratio of KCF to fellows of at least 1:1.5 mustbe maintained. The availability and funding for this time forthe program director and KCF is problematic, particularly forsmaller programs. In addition, the ACGME work-hour limitationson fellows has led to the transfer of care of some patientsfrom fellows with faculty supervision to faculty only requiringa greater financial commitment to cover this additional facultytime.
A second challenge pertains to evaluating fellows on the sixgeneral competencies that now are required in residency andfellowship programs (patient care, medical knowledge, practice-basedlearning and improvement, interpersonal communication skills,professionalism, and systems-based practice). Starting in July2006, a single evaluation method is no longer sufficient toassess the competence of a trainee. Programs must demonstrateat least two methods of evaluation for each of the competencies.The ACGME recommends development of a structured portfolio foreach trainee that includes foundational evaluations, directobservations, practice and data-based learning, and multisourceevaluations (9). The use of an outcomes-based evaluation systemwill enhance the feedback that fellows receive about their performance.However, the development of valid and reliable tools by individualprograms and the training of faculty in these evaluation techniquesare challenging to individual programs. These challenges canbe met in a number of different ways. The ACGME and the GMEcommunity need to determine whether these more stringent competencyrequirements affect such outcomes as quality of trainees orpatient care. Existing evaluation tools need to be shared amongtraining programs, with the ACGME taking the lead in offeringtheir vision of "best tools" to training programs. New methodsfor assessing the six competencies need to be developed andassessed for their effectiveness. Finally, a plan to share existingevaluation tools and methods on a central Web site is beingdeveloped by the American Society of Nephrology (ASN) trainingprogram directors.
In-Training Examination in Nephrology
The Association of Specialty Professors (ASP) has launched aninitiative to have all fellowship programs implement formalin-training examinations no later than the year 2010, as iscurrently done for internal medicine and other residency programs.An in-training examination would be used to evaluate formallythe knowledge of trainees and can serve as an independent predictorof performance on the ABIM examination for board certification.The examination can also be used by programs to identify deficienciesin training. Having such a tool will help in the assessmentof the core competencies of medical knowledge and patient careand can provide an opportunity to survey all trainees on issuessuch as recruitment, career choice, and practice plans.
Although some specialty fellowship programs have already developedan in-training examination, the majority of programs have onlybegun the process or have not yet taken the necessary steps.There are financial advantages of bringing subspecialties togetherwhen programs use a standardized set of services and uniformprocesses. More important, common pools of questions can bedeveloped to assess areas of common interest, such as end-of-lifecare, ethics, and continuous quality improvement. The ASP intervieweda number of different vendors before recommending the NationalBoard of Medical Examiners (NBME) as the vendor of choice forthe development, administration, and scoring services for thesubspecialty in-training examinations. NBME is a not-for-profitinstitution whose mission is to provide high-quality testingand research services to organizations that are involved inthe licensure and certification of health care professionals.The NBME is most notable for its role in developing and administeringthe US Medical Licensing Examination and for administering theinternal medicine in-training examination.
The ASP and NBME hosted a meeting with representatives fromsubspecialties that were interested in discussing fellowshipin-training examinations on May 30, 2006. Nephrology, with thesupport of the ASN and its Training Program Directors Committee,agreed to move ahead with the development of an in-trainingexamination. The next steps are to host a question (item)-writingworkshop to develop a pool of questions and to select an In-TrainingExamination Committee of interested volunteers to move thisinitiative forward. The tentative date for the first examinationin nephrology is the spring 2009. This will allow sufficienttime to develop a high-quality examination. The working modelfor the examination is for it to be Web based and consist ofapproximately 250 questions. The cost for the examination isprojected to be $200 to $220 dollars per fellow per year.
Nephrology Match
The National Resident Matching Program (NRMP) is a private,not-for-profit corporation that was established to provide auniform date of appointment to positions in GME in the UnitedStates. The Specialties Matching Service of the NRMP conductsmatches for advanced residency or fellowship positions. Formatching services to be provided, each specialty must verifythat at least 75% of programs with available positions in agiven year are registered for the match, encourage programsto participate actively by submitting a rank-order list, andhave at least 75% of the available positions within the specialtyregistered with the NRMP. Not all programs and not all positionsin any one program must be in the match.
Medical specialties that participate in the match and the yearthey joined the match are as follows: Cardiovascular disease(1986), gastroenterology (1986 to 1999; rejoined in 2006), hematology(2006), hematology/oncology (2006), infectious disease (1986to 1990; rejoined in 1994), oncology (2006), pulmonary and criticalmedicine (1986), and rheumatology (2005). The medical specialtiesthat are not participating in the match at the present timeare nephrology, endocrinology, diabetes and metabolism, sleepmedicine, and geriatric medicine.
To assess the interest level for a match, a Web-based surveywas conducted by the ASN in February 2006 and targeted all adulttraining program directors in nephrology. In response to thequestion, "Should there be a match for nephrology?" 61.8% ofnephrology training program directors said yes and 38.2% saidno (n = 102). Potential disadvantages of the match are discussednext and were cited in the survey as reasons for not wantingto participate in the match. When internal medicine residentswere surveyed in 2001, 69% of the respondents believed thatthe fellowship application process for all programs occurredtoo early for them to make an informed decision (10). A similarpercentage of residents surveyed preferred a uniform startingdate for offering appointments.
Disadvantages for nephrology participation in the match includethe following:
The current system for selecting fellows is familiarand isworking well for many programs. Changing the selectionsystemwould raise the level of uncertainty beyond a thresholdthatwould be comfortable for some programs.
The match woulddecrease flexibility particularly for programsthat very specificallymatch a given candidate with a specificlaboratory. Also, forsome programs, the decision about positionsis an iterativeprocess and therefore dependent on which candidatesaccept theinitial offers. This flexibility would be decreasedwith thematch.
Programs would have to interview more candidates togeneratetheir match list. This would be expensive and time-consuming.
A match requires widespread support of all training programsto ensure compliance. Many program directors recalled the failureof a previous nephrology match that was held more than 20 yrago during which many programs offered positions outside thematch, disadvantaging those who participated. Currently, therules are stricter and the applicant pool is larger.
The matchcreates a level of uncertainty regarding which candidateswillmatch with a given program, potentially leading to unsatisfiedcandidates and/or programs.
Advantages for nephrology participation in the match includethe following:
The match provides applicants and programs withthe time andthe opportunity to make an informed decision. Forprograms thatare participating in the match for the 2007 academicyear (startdate July 1, 2007), the dates for submitting rank-orderlistsfor applicants and programs began April 12, 2006, andendedJune 7, 2006. Match Day was June 21, 2006. This timelineallowsprograms and applicants a longer interview season. Applicantsno longer have to make career choices during their internshipyear before they have had the chance to do electives, performresearch, or establish the necessary contacts for letters ofreference.
The match would provide order to what has beena chaotic applicationprocess. The interview season would becomemore standardized,creating an even playing field for nephrologyfellowship programsto compete.
Absence of a match placesundue pressure on applicants. A frequentcomplaint of applicantswas that after interviewing at a specificprogram, they weretold to decide within a short time framewhether they were interestedin the program. Many had futureinterviews scheduled and hadto decide between accepting thecurrent early offer or continuingwith these interviews.
The longer interview season would preventthe disruptive consequencesof applicants accepting an earlyoffer and then resigning theoffer after choosing a programthat they preferred but had alater interview date.
Thereis greater potential for applicants to choose programsotherthan their own when there is a more uniform interviewseasonincluding a match. This has been seen with the GastroenterologyMatch (11,12). Such cross-fertilization has many advantagesto programs and applicants, including diversity of ideas andexperiences.
The match offers programs flexibility in decidinghow many tracksthe program offers and how these tracks arefilled. There canbe separate tracks for research and clinicalpositions withina participating program. For example, researchtracks in theGastroenterology Match are further subdividedinto basic scienceand clinical research (11). There is alsoflexibility for positionsto be moved between tracks at thetime of the actual match.If a nephrology program has threepositions and wants to filltwo positions in a clinical trackand one in a research track,then the program would submit separaterank-order lists foreach track. If the research position didnot fill, then theprogram could elect to revert the positionto its clinical trackand the matching algorithm would attemptto fill the researchposition from the clinical track's rank-orderlist. The programcan determine the order in which the differenttracks for aprogram are filled. Also, applicants can applyfor one or moretracks within a given program. Therefore, programscan customizethe matching process.
The number of applicantinterviews that a program conducts islikely to increase withparticipation in the match. However,this can be a positiveconsequence because it allows programsand applicants to considerall options before making decisionsand removes the pressureon programs to accept reasonable applicantsbefore completingall interviews.
Without a match, nephrology is potentiallyfalling behind otherspecialties that participate in the match.When the career plansof internal medicine residents who tookthe 2005 Internal MedicineIn-Training Examination were examined(n = 17,258), 5.5% (n= 949) were interested in nephrology (13).This number of potentialapplicants is more than the actualnumber who applied for 2007(n = 757; Table 2), although thepopulations are likely different.Of the group surveyed, 12.3%were undecided, 12.9% were goinginto cardiology, and 8.5% weregoing to gastroenterology. Thelack of a uniform applicationand acceptance process is a potentialbarrier for choosing nephrologyfor undecided but high-qualityapplicants.
After the match,information is available to the training programregarding thechoice of ranked applicants who did not matchwith their program.This information can be valuable to programsfor improving theirrecruitment strategies in the future.
The advantages and disadvantages of the match have to be carefullyassessed by programs as they decide whether to participate inthe match. In my opinion, the current application and acceptanceprocess is chaotic, disadvantages the candidates, and couldpotentially impair our ability to recruit high-quality candidatesinto nephrology. A match in nephrology would build trust andgood faith between our specialty and the applicants, as wellas between training programs.
Workforce Needs
According to the AAMC Physician Specialty Data report (http://www.aamc.org)that used the American Medical Association Physician Masterfile(January 2006), 6891 nephrologists were listed as active physicians.This translates to 43,300 people per nephrologist in the UnitedStates compared with 3000 for general internal medicine, 7900for psychiatry, and 26,000 for gastroenterology. Approximately30% of nephrologists were aged 55 or older. The number of nephrologistsincreased by 1804 between 1995 and 2004. The production rateof nephrologists, defined as the ratio of first-year fellowsin ACGME-accredited nephrology training program to active nephrologists,is approximately 5%, a rate that is similar to that of internalmedicine. For comparison, the production rate for internal medicinesubspecialties varies from a high of 44% for interventionalcardiology to a low of approximately 4% for gastroenterology.
A comprehensive report on workforce and training requirementsfor nephrology was conducted by the ASN and its sister societies,the National Kidney Foundation (NKF), the Renal Physicians Association,the American Society of Transplant Physicians, and the AmericanSociety of Pediatric Nephrology, and was published in 1997 (14,15).At the time of the survey, 235 nephrology trainees graduatedfrom nephrology training programs, acquiring specialty certificates.The report concluded that nephrology has not been training newnephrologists beyond anticipated need and that training programswould need to expand. In fact, the number of trainees wouldhave had to increase by 200 trainees for each year between theyears 1996 and 2010 to meet conservative workforce estimates.The number of actual graduates is plotted in Figure 1. In 2005,the number of new graduates was 366, the highest number in recentyears, but the growth is well short of projected needs. Similarprojected workforce shortages in nephrology have been reportedby others (16–18).
Lack of funding is the major limitation to expanding the numberof nephrology trainees. The Balanced Budget Act of 1997 cappedthe number of Medicare-funded GME positions (19,20). Despitethis lack of funding, the number of nephrology fellowship graduateshas increased (Figure 1), reflecting the use of alternativefunding sources or redistribution of training positions withininstitutions. No data are available regarding which of thesepossibilities has occurred more often or the source of additionalfunds. In addition, it has been increasingly difficult to payfor the research training that is needed for both the mandatoryscholarly activity that is required of all trainees by the ACGMEand the more extensive research training of fellows who planto have an academic research career. Growth is further hamperedby the growing uncompensated effort that is required to trainfellows given the ACGME requirements for hours devoted to trainingby program directors and key faculty (8). Finally, not all graduatesof US training programs will join the clinical workforce. Forexample, 40% of graduates are IMG, some of who return to theirhome countries to practice (Figure 2).
Solutions to the projected workforce shortage in nephrologyare either to decrease demand for nephrologists or to increasesupply. The demand for nephrologists is unlikely to decreasegiven the rising incidence of ESRD (although this may be stabilizing)and the growing involvement of nephrology in the managementof the early stages of chronic kidney disease. On the supplyside, new strategies for funding nephrology training have tobe developed. The case needs to be clearly made regarding projectedworkforce shortages in nephrology. Nephrology should join forceswith other subspecialties under the leadership of organizationssuch as the ASP and the Association of Professors of Medicineto address the future of funding for GME. An issue that nephrologycan specifically address relates to the fact that hospitalsreceive only half of the financial support (payment for indirectmedical education) for fellows in subspecialty training comparedwith residents in "primary care" specialties. The case shouldbe made to designate nephrology a "primary care" specialty thatserves a defined chronic disease population. Doing so wouldqualify hospitals for a higher level of reimbursement and shouldhave advantageous downstream effects for nephrology trainingprograms. New and existing partners need to be approached tofund additional clinical nephrology fellowship positions. Examplesof new partnerships include affiliated hospitals, nephrologypractices, or even large health plans along the lines of an"all-payer" fund. Organizations that currently fund nephrologyresearch, such as the National Institutes of Health, ASN, NKF,American Heart Association, and Juvenile Diabetes Foundation,should also be approached with new ideas to enhance the fundingof nephrology research training.
Subspecialization in Nephrology
The ABIM is the US specialty board that "sets the standardsand certifies the knowledge, skills, and attitudes of physicianswho practice in internal medicine and its subspecialties." Asingle examination and certification for nephrology is available.As part of the new uniform recognition of all subspecialties,the ABIM offers certification of newer subspecialties in otherfields, including adolescent medicine, clinical cardiac electrophysiology,critical care medicine, geriatric medicine, interventional cardiology,sleep medicine, sports medicine, and transplant hepatology,under the designation "subspecialties of internal medicine."
As with other internal medicine specialties, nephrology is becomingmore subspecialized, with additional training available fortransplant and interventional nephrology. An additional yearof training in transplant nephrology is available through programsthat are accredited by the American Society of Transplantationand the ASN to provide subspecialty training to nephrologists,qualifying them to head United Network for Organ Sharing–approvedrenal transplant programs. There are 42 accredited renal transplanttraining programs in the United States (http://www.a-s-t.org/accreditation/AST-ASN_accredited.htm).
The American Society of Diagnostic and Interventional Nephrologyhas defined criteria for the certification of interventionalnephrologists and the accreditation of programs in ultrasonography,insertion of peritoneal dialysis catheters, endovascular procedureson arteriovenous fistulas and grafts, and placement of chronicvenous catheters for hemodialysis (http://www.asdin.org/) (21).Neither transplant nephrology nor diagnostic and interventionalnephrology is ACGME accredited or recognized as a subspecialtyby the ABIM.
In the future, there will be growing pressure to recognize formallythese subspecialties in nephrology. Such recognition has importantimplications for the general discipline of nephrology and fortraining programs in particular. On the positive side, thesesubspecialties have a distinct and unique body of knowledgeand skill sets that should be recognized. Formal recognitionof these programs could potentially open up funding sourcesfor training that are limited in most institutions to ACGME-approvedprograms. On the negative side, dividing nephrology into distinctsubspecialties has the potential to fragment the specialty.Aspects of transplant and interventional nephrology are partof the training of all nephrologists. Subspecialization mayplace limitations on the practice of general nephrology. Thiscould lead to heterogeneity of care such that a dialysis patientwould need to be referred to a transplant nephrologist oncethat patient undergoes a kidney transplant.
Options for dealing with subspecialization in nephrology includenot doing anything to keep nephrology as a single specialty.Alternatively, transplant nephrology or interventional nephrologycould apply to the ABIM for designation as a separate subspecialtyin internal medicine, similar to what was done for transplanthepatology. More moderate options would be to work with theABIM to develop either special certifications for the areasof transplant nephrology and/or interventional nephrology orrequest "focused recognition" within the structure of the maintenanceof certification program. Subspecialization will continue tobe a challenge and should be approached with a careful and thoughtfulreview of these and other issues to allow for the harmoniousintegration of all aspects of nephrology.
The number of nephrology fellowship programs and trainees inthe United States has continued to increase slowly despite fundinglimitations. This growth is not large enough to meet previouslyestimated workforce needs. Also, there is a pronounced shortageof minority nephrologists (18). Training programs have to facea more stringent regulatory environment and increased demandson faculty time. Additional training is available in transplantnephrology and diagnostic and interventional nephrology. Theintegration of these subspecialties into the overall trainingand certification of nephrologists remains an open issue. Despitethese challenges, there are many ways in which training programscan come together to enhance the nephrology fellowship experienceand ultimately the care of nephrology patients. Lobbying forgreater funding of fellowship programs should be done on a localand national level. Evaluation tools can be developed and sharedamong programs, including the proposed in-training examination.Programs can cooperate to ensure the future diversificationof the nephrology workforce to reflect better the patient populationserved. The application and selection process for trainees shouldevolve to reinforce the principles of professionalism and fairnessthat exist in our discipline. Training our future workforceremains one of the most important responsibilities in nephrologyand needs to be approached with intensity, innovation, and integrity.
I am grateful to Sharon Anderson and Ben Bornsztein for reviewingthis manuscript.
Footnotes
Published online ahead of print. Publication date availableat www.jasn.org.
Although the author served as chair of the Training ProgramDirectors Executive Committee of the American Society of Nephrology(ASN) from 2003 to 2006, the views expressed in this articleare those of the author and not of the ASN or the members ofthe Executive Committee.
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Top
Abstract
Introduction
