Education in Nephrology Fellowship: A Survey-Based Needs Assessment

Respondent Demographics

Overall, 377 of 1218 fellows to whom ASN offers complimentary membership completed the survey (31% response rate). Respondents in their first or second year of ACGME-accredited adult nephrology training were included in the analysis (320 fellows). Included respondents represented 37% (320 of 863) of ACGME-accredited fellows for the same academic year (2015–2016). Demographics are outlined in Table 1. With respect to age, sex, and race, respondents were similar to the overall cohort of fellows according to the most recent ACGME data. However, there were statistically significant differences between respondents and the ACGME cohort in the location of medical school of record (United States versus international medical schools) and medical degree (Doctor of Medicine versus Doctor of Osteopathic Medicine).

Quality and Educational Makeup of Fellowship Teaching

Most respondents described the overall quality of fellowship teaching as either “good” (37%) or “excellent” (44%) (Figure 1). Similarly, almost one half of second-year respondents (42%) felt “moderately prepared” for independent practice, and more than one half (55%) felt “fully prepared” (Figure 2). Second-year fellows felt more prepared than first-year fellows (P<0.01; chi-squared test for independence).

• Download figure
• Open in new tab
• Download powerpoint

Figure 1.

Fellows have positive perceptions of the overall quality of their training. Bars indicate the percentages of respondents for each assessment class.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2.

A majority of second-year fellows report moderate or full preparedness for independent practice.

Although the prior 2010 Berns⁶ survey did not assess overall preparation for independent practice, the percentage of respondents indicating that they were well trained and competent ranged from approximately 80% for in-center hemodialysis and transplant care to 15% for HHD care. Further characterizations of nephrology fellows’ overall preparation for independent practice are not present in the literature. In contrast, a 2001 survey of graduating internal medicine residents found that, although 91% felt very prepared to care for inpatients independently, only 48% felt very prepared for the ambulatory setting.¹⁶

Importantly, anchor effect bias within a Likert scale may increase the selection of moderate choices rather than extremes and underestimate the number of fully prepared fellows.¹⁷ However, although this subjective measure of preparedness for a future and as yet unknown job is flawed, it is likely that this preparedness gap is at least partially generated by educational deficiencies in fellowship. Educational innovations designed to improve global performance will likely reduce this gap.

Educational Modalities and Resources

Participants were asked to identify educational modalities and resources used in fellowship. Table 2 details educational modalities that respondents indicated were used in their fellowships. Traditional modalities (e.g., journal clubs, lectures, and grand rounds) predominated, with between 72% and 90% of respondents reporting their use. Other modalities, including protected time for physiology and clinical nephrology review, reading lists, simulation training for catheters or biopsies, communications training, and ultrasound training, were reported by <50% of respondents.

These results suggest that the general educational structure, as perceived by fellows, is reasonably similar among programs given the prevalence of traditional educational modalities, such as curriculum lectures, journal clubs, and grand rounds. A recent survey of nephrology training program directors also indicated that these modalities are nearly universal.¹⁸ In this survey, simulation training was perceived as less prevalent than expected given the ACGME mandate to include simulation in curricula.¹³ Although respondents may not have understood the variety of simulation training that may be included in their fellowship and although the survey did not include all potential simulation curricula, this discrepancy raises concern. Fellows’ receptiveness to additional simulation training seemed mixed. Respondents reported that they were less likely to participate in simulation training for catheter placement, biopsies, or communication skills compared with other strategies. In contrast, the desire for biopsy and ultrasound training was emphasized in answers to a free response question about educational improvements (discussed below). Notably, there is at least preliminary evidence to support the use of simulation in nephrology education.^11,19–22

Fellows were also asked to report extracurricular resources used within the last 3 months (Table 3). UpToDate was nearly universally used, with the Clinical Journal of the American Society of Nephrology, the Journal of the American Society of Nephrology, and the ASN Nephrology Self-Assessment Program used by a majority of respondents.²³ However, several expert-led and potentially effective educational resources, such as the American Journal of Kidney Disease (AJKD) Kidney Core Curriculum, the Renal Fellow Network blog, Nephrology Journal Club, the AJKD blog, and the ASN online curricula, seem less utilized.^24–28 These resources deliver content on topics requested by respondents in this survey, such as home dialysis modalities and GN, and their heightened focus on social media formats may prove useful for digital learners. Formal evaluation of their usefulness and dissemination of the content through effective avenues would be valuable for fellows and their programs.

Educational Content Needs and Suggestions for Improving the Educational Environment

Participants were asked to identify topics that they would like additional instruction in during fellowship (Table 4). Top desired topics (>30% responding) included home dialysis modalities (PD and HHD), radiology and pathology interpretation, obstetric nephrology, GN, and toxicology, suggesting an educational need in these areas; 10% or fewer of fellows desired further instruction in topics, such as AKI management, outpatient CKD management, or diabetic nephropathy.

A total of 100 of 320 participants (31%) responded to the open-ended question: “Describe two changes that could improve your fellowship’s educational environment.” Responses centered on two themes: (1) structural changes and (2) desires for specific educational content. Structural changes included requests for more protected time to study independently, lectures and presentations sheltered from the competing interests of clinical care (e.g., “[a]llow ‘pager free’ time so that focus can be given to lectures”), and more faculty involvement in curricular development and implementation. Suggestions for educational content centered largely on increasing emphasis in four content areas: procedures (e.g., “[p]rovide protected time for simulations programs, i.e., reading [ultrasounds] dialysis catheter placement”), home dialysis modalities, ultrasound and other renal imaging, and renal pathology and physiology. Further representative quotes are listed in Table 5.

The content areas identified by fellows for additional educational emphasis align with those topics previously identified in the Berns⁶ 2010 survey of recently graduated nephrologists.

The need for additional training in home dialysis modalities is especially notable given the desire to expand these patient-centered and potentially less expensive options. Without strengthening fellowship training in these key therapeutic options, the full adoption of these modalities across the specialty will be difficult.

Future Educational Innovations

Lastly, fellows were surveyed on how likely they were to participate in educational interventions reflective of the nephrology educational literature and traditional educational modalities (Table 6). Respondents viewed all potential interventions at least neutrally in aggregate. However, fellows were more likely to participate in renal pathology conferences and “dedicated time for renal physiology, pathophysiology, and/or clinical nephrology review.”

Although interest in simulation within this survey seems mixed, the ability of simulation curricula to increase fellows’ procedural competence should continue to be explored. A lack of procedural confidence and opportunities in fellowship, beyond representing a potential educational challenge, may be a deterrent to recruiting fellows who enjoy working with their hands or are concerned about limited revenue potential in nephrology.²⁹

The use of novel educational tools in nephrology has vastly expanded in the last two decades.^30–33 Although recent literature has emphasized the potential for educational innovations to improve nephrology training, consistent outcome data are lacking.^34–37 These methods, including but not limited to social media (e.g., blogs, Twitter, and physician networks), connectivity aids (e.g., audience response systems and lecture capture), video production, clinical debates, and medical gaming, provide opportunities to create interactive and captivating education placed within a clinically relevant context at all trainee levels. Importantly, although nephrology has taken a strong place in the nascent development of social media educational tools, our understanding of their efficacy remains limited.³⁸ Assessing and expanding innovation in nephrology education may not only improve education of trainees but also, given the connection between education and interest in nephrology, help address the growing disinterest in our field.^29,39,40

Parallel with these developing educational tools, the ASN has also sponsored recent workforce activities, including (1) the Kidney Tutored Research and Education for Kidney Students Program, which provides medical students core physiology education as well as ongoing mentorship and scholarship experiences that seem to increase interest in nephrology as a career choice; (2) the Mentoring and Awareness Program for Students, a community CKD screening program; and (3) the Kidney Students and Residents Program, which provides travel grants to medical students and residents to attend ASN Kidney Week.^41–44 Moving forward, the longitudinal assessment of participants in these programs is a priority for the ASN leadership.

Limitations of the Survey

This study has several limitations, most notably the limited response rate. Multiple approaches to improving participation were used and are discussed in Supplemental Material. Although the response rate may limit the generalizability of the results, this survey represents, to the best of the authors’ knowledge, the largest sampling of nephrology fellows within an educational study to date. Furthermore, respondents were representative of the ACGME fellows cohort in terms of age, sex, and race. The limited response rate may also have contributed to the variance in responses regarding future educational modalities, limiting our ability to discriminate between interventions. Unfortunately, increasing follow-up outreach beyond what was performed has not been associated with improved response rates, and direct financial incentives, which are effective, were unavailable (aside from a chance at winning complimentary ASN membership or Board Review Course and Update registration).⁴⁵ Future studies may benefit from these incentives as well as consideration of inclusion within the national fellow in-training examination to improve response rates.

It also must be recognized that surveys may accentuate the concerns of a minority of vocal respondents, further limiting generalizability. As discussed earlier, fellows in training inherently lack the perspective that comes from independent practice, which may partially explain the reduced interest in some topics (e.g., end of life care/geriatric nephrology, nutrition, and outpatient CKD management). However, in limiting this survey to current fellows rather than practicing nephrologists, we could better assess what educational interventions are more likely to be supported by fellows. Future studies should endeavor to capture a greater totality of current fellows’ experience and further incorporate the evolving educational tools that we are developing.