Procedures during nephrology training – time to reconsider?

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Mukesh Sharma (University of Nevada Reno School of Medicine, Reno, USA) is a member of the faculty at the American Society of Diagnostic and Interventional Nephrology (ASDIN). Here, he examines the unique capabilities of the interventional nephrologist, and the importance of nephrologists learning procedures such as catheterisation during their training. 

Nephrology as a medical subspecialty blends intricate knowledge of physiology with clinical reasoning, encompasses building long-term patient relationships, and offers a gamut of surgical procedures for diagnostic and therapeutic implications for patients with kidney disease. The emergence, evolution, and establishment of interventional nephrology as a subspecialty has added further credence to the claim that nephrologists, adequately trained, are in a unique position and well-equipped to provide dialysis access services to patients with whom they have long-term care relationships established already. 

Whereas a case can be made that promoting procedural training during fellowship may help lure more applicants to lift the sagging number of applications for the US Nephrology fellowship programmes, a hot debate has emerged regarding whether future generations of nephrologists should even be required to do a certain number of procedures during their training. These requirements currently include temporary vascular access placement for haemodialysis and kidney biopsy. 

Such questions about the utility of busy clinical nephrologists doing procedures gained prominence after the American Board of Internal Medicine (ABIM) 2021 procedural frequency survey results.  The survey was sent to over 10,000 nephrologists asking them if they were performing procedures like kidney biopsy and temporary dialysis catheters in their day-to-day practice. Of these, 70.9% of the respondents said that they no longer performed temporary vascular access, and 14.7% performed between one and five procedures per year. For kidney biopsy, 83.1% of respondents no longer performed kidney biopsies, and only 6.9% performed between one and five biopsies per year. 

In my opinion, the results of the ABIM survey need to be analysed carefully before conclusions are drawn. First, the response rate on this survey was quite low (19.7%) and should not be generalised to the entire nephrology community. The views and opinions of the rest of the nephrologists who did not respond to the survey (81.3%) are hard to predict based on the lukewarm response to the survey. Even if the survey results are to be generalised, 30% of nephrologists still place an emergent temporary dialysis catheter at least once a year. On a national level, there are an estimated 10,000 adult nephrologists in the USA, and extrapolating the data from the above survey reveals that there are about 3,000 nephrologists that place a temporary dialysis catheter usually in emergent situations. 

As such, it is imperative that the nephrology fellows get adequate training during fellowship to gain the competency and confidence to place a temporary dialysis catheter to deal with emergent lifesaving scenarios and perform a kidney biopsy when required. This sentiment is shared and supported by nephrology fellows in general as well. The American Society of Nephrology (ASN) established a taskforce in April 2022 to deliberate on all aspects of future nephrology including the procedural requirements for nephrology fellowship programmes. The nephrology fellows themselves feel and have conveyed to the ASN taskforce that they should continue to do such procedures. To quote directly from the ASN taskforce discussion, the current nephrology fellows felt that they are “giving away procedures when other specialties were not”. They also felt that it was important for nephrologists to perform procedures because it was best for patients and avoided fragmenting care, and procedures were one way to attract future applicants. 

As ‘value-based care’ models gain wider acceptance across different payers, it is likely to add more disincentives for referring patients to other specialists for common procedures.  The literature supports that nephrologists can competently perform common dialysis access procedures with outcomes comparable and in some cases better than those performed by their colleagues from other subspecialties. Being proficient and competent to do procedures will help the next generation of nephrologists survive and thrive in the evolving value-based healthcare ecosystem. We must continue to equip and train future nephrologists with proper procedural training, and American Society of Diagnostic and Interventional Nephrology (ASDIN) can play a major role, along with ASN, in helping to form our future nephrologists. 

References: 

  1.  Update on the Task Force on the Future of Nephrology. Reimagining Nephrology Fellowship Training. Mark RosenbergKidney News, Volume 14, Issue 7, Publication date: 01 July 2022, pp 10–11 
  1. The Nephrology Workforce 2016, ASN, 2016, Exhibit 1, p7. Available at https://www.asnonline.org/education/training/workforce/Nephrology_Workforce_Study_Report_2016.pdf 
  1. The ASN Task Force on the Future of Nephrology: What Have We Been Hearing? Kidney News, Volume 14: Issue 9, Publication Date: 01 Sep 2022 Page: 14 
  1. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Gerald A. Beathard, Terry Litchfield. Kidney International, Volume 66, Issue 4, October 2004, Pages 1622-1632. https://doi.org/10.1111/j.1523-1755.2004.00928.x 

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