The Workforce in Critical Care Nephrology: Challenges and Opportunities.

The substantial burden of acute kidney injury and end-stage kidney disease among patients with critical illness highlights the importance and need for a specialized nephrologist in the intensive care unit. The last decade has seen a growing interest in a career focused on critical care nephrology. However, the scope of practice and job satisfaction of those who completed dual training in nephrology and critical care are largely unknown. This article discusses the current practice landscape of critical care nephrology and describes the educational tracks available to pursue this pathway and considerations to enhance the future of this field.

Nephrology Fellows' and Program Directors' Perceptions of Hospital Rounds in the United States.

BACKGROUND AND OBJECTIVES: Hospital rounds are a traditional vehicle for patient-care delivery and experiential learning for trainees. We aimed to characterize practices and perceptions of rounds in United States nephrology training programs. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a national survey of United States nephrology fellows and program directors. Fellows received the survey after completing the 2019 National Board of Medical Examiners Nephrology In-Training Exam. Program directors received the survey at the American Society of Nephrology's 2019 Nephrology Training Program Directors' Retreat. Surveys assessed the structure and perceptions of rounds, focusing on workload, workflow, value for patient care, and fellows' clinical skill-building. Directors were queried about their expectations for fellow prerounds and efficiency of rounds. Responses were quantified by proportions. RESULTS: Fellow and program director response rates were 73% (n=621) and 70% (n=55). Most fellows (74%) report a patient census of >15, arrive at the hospital before 7:00 am (59%), and complete progress notes after 5:00 pm (46%). Among several rounding activities, fellows most valued bedside discussions for building their clinical skills (34%), but only 30% examine all patients with the attending at the bedside. Most directors (71%) expect fellows to both examine patients and collect data before attending-rounds. A majority (78%) of directors commonly complete their documentation after 5:00 pm, and for 36%, after 8:00 pm. Like fellows, directors most value bedside discussion for development of fellows' clinical skills (44%). Lack of preparedness for the rigors of nephrology fellowship was the most-cited barrier to efficient rounds (31%). CONCLUSIONS: Hospital rounds in United States nephrology training programs are characterized by high patient volumes, early-morning starts, and late-evening clinical documentation. Fellows use a variety of prerounding styles and examine patients at the beside with their attendings at different frequencies. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_03_17_CJN.10190819.mp3.

Leadership in the Industry Arena: Nephrologists in Nonclinical Leadership Roles.

Of late, fewer residents are choosing nephrology as a career. Contributing factors may include lack of prestige, uncertain potential of future income, and poor work-life balance. Some current nephrologists are considering transitioning to another career for similar reasons. For those who decide that practicing nephrology is no longer appealing, there are many available avenues where they can use their nephrology expertise and still have a successful future. A leadership role in the pharmaceutical industry is a potentially attractive and viable option to nephrologists who are ready to transition to a different career. As industry-sponsored clinical trials increase in number, there will be a need for more nephrologists at entry and higher level positions. This in turn will lead to more nephrologists advancing to senior management and who will then be positioned to advocate for further investments in nephrology, thereby opening the door for other nephrologists to join the industry.

Changing Trends in the Performance of Percutaneous Renal Biopsy from Nephrologist to Interventional Radiologist: A Single-Center Experience.

BACKGROUND: Percutaneous renal biopsy of native kidneys (PRB) has been an integral part of the practice of nephrology. However, over the past 30 years, PRB has transitioned from a procedure performed only by nephrologists to interventional radiologists (IRs). We surveyed practicing nephrologists completing training in our program to determine the clinical practice patterns of PRB. METHODS: The 78 fellows completing the nephrology program at Rush University Medical Center from June 1984 through June 2017 were successfully contacted and surveyed regarding their opinion on adequacy of their training and whether they performed PRB in practice and if not or no longer, why. To evaluate for differences in the performance of PRB over time, a comparison of 4 periods of fellowship completion (i.e., 1984-1990, 1991-2000, 2001-2010, 2011-2017) was performed. RESULTS: All 78 nephrologists felt they had been adequately trained to perform PRB. PRB was performed by 45 (58%) nephrologists post-fellowship, but a significant decline was observed over the 4 periods of time from 1984 to 2017 (100 vs. 86 vs. 52 vs. 20%, p < 0.0001). The primary reason that 33 nephrologists did not perform PRB was that it was too time consuming and IR was available to perform PRB. Of the 71 nephrologists still in practice only 12 (17%) continue to perform PRB. A greater proportion of nephrologists completing training from 1984-1990 continue to perform PRB relative to those trained after 1990. The universal reason that nephrologists were no longer performing PRB was again an issue of time and the fact that IRs were available to perform PRB. CONCLUSION: We find that there has been a significant transition over time in the performance of PRB by a nephrologist to IR. The major reason for this is the time burden associated with PRB and the availability of IRs.

Dialysis access procedure training for the nephrologist.

Historically, the placement and maintenance of dialysis access has been an integral part of nephrology training. However, in recent years, a big debate has ensued regarding whether this should be limited to trainees' understanding and counseling the patients regarding indications, alternatives, risks and possible complications of these procedures or should it actually involve more of a hands-on experience for the trainees. Some of the barriers in making these procedures a requirement across the board are the lack of standardization of procedural training across various training programs and the absence of consensus on what achieving competency in these procedures looks like. However, in the era of declining interest in nephrology, giving up "ownership" of nephrology procedures and increasing reliance on other sub specialties might be a deterrent in attracting residents to this field; we have to make a concerted effort to increase the exposure and opportunities for the trainees to perform these procedures. Moreover, we need to emphasize the implementation of a curriculum for nephrology fellows to evaluate access properly in order to decrease the burden of access related complications. Lastly, we need to continue working towards a more structured curriculum for a dedicated interventional nephrology fellowship for trainees who want to focus on procedures for their long-term career goals.

Resuscitation for the specialty of nephrology: is cardionephrology the answer?

The specialty of nephrology faces major fellowship recruitment challenges, with ongoing declining interest among internal medicine residents. The field of Cardionephrology can help instill new interest and enthusiasm in choosing nephrology as a career amongst trainee physicians.

Nephrology training in Australia and New Zealand: A survey of outcomes and adequacy.

BACKGROUND: Advanced training programmes in nephrology should provide broad exposure to all aspects of nephrology. In Australia and New Zealand (ANZ), the Advanced Training Committee in Nephrology oversees training, and recent increases in trainee numbers have led to concern about dilution of experience. AIM: To investigate early career paths of nephrologists in ANZ and determine the adequacy of training by comparing self-determined competency and skill relevance among recently graduated nephrologists. METHODS: In 2015, the Advanced Training Committee in Nephrology administered an online survey during the annual subscription for members of the Australian and New Zealand Society of Nephrology. Nephrologists who were awarded Fellowship after 2002 were invited to participate. RESULTS: The survey was completed by 113 Fellows with 8 respondents excluded (response rate 44.1%). Initial post-Fellowship work included full-time public hospital appointments (34.3%) or undertaking full-time higher research degrees (41.9%). The majority reported securing their desired employment. Respondents indicated adequate training in most clinical skills; however, responses of 'well trained' in home haemodialysis (41.8%), conservative care (42.9%), automated peritoneal dialysis (38.8%), and assessment of kidney transplant recipients (48%) and living kidney donors (34.7%) were less adequate. Although considered highly relevant to current practice, responses of 'well trained' were low for management and research skills, including complaint management (16.3%), private practice management (2%), health system knowledge (14.3%) and regulations (6.1%), ethics approval (23.5%), research funding (11.2%) and quality assurance (26.5%). CONCLUSION: Nephrology training in ANZ generally meets clinical needs and most secure their desired employment. Training in management and research are areas for improvement.

Outpatient removal of tunneled dialysis catheters by nephrology fellows in training at a Veterans Affairs Medical Center.

BACKGROUND: Removal of tunneled dialysis catheters (TDC) usually occurs in dedicated procedure suites and is performed relatively rarely at the bedside. Scarce evidence exists in the literature to assess the safety and success of this procedure when performed during supervised academic training. PATIENTS AND METHODS: We conducted a retrospective chart review of all TDC removals performed on an outpatient basis by nephrology fellows under faculty supervision during a 5-year period at an academic Veterans Affairs Medical Center. Data were collected regarding patient demographics, basic laboratory studies, pertinent clinical information and procedure-related variables. We evaluated the safety, success and complication rate of this procedure. RESULTS: We identified 72 TDC removals that met the above criteria. Mean age was 63 ± 10 years. All patients were male and hypertensive, 68% were diabetic and 69% were African-American. Overall, 88% of procedures were performed in end-stage renal disease (ESRD) patients, while the rest had needed temporary dialysis for acute kidney injury. Notably, 49 patients (68%) were taking one or more of aspirin, clopidogrel or warfarin at the time of TDC removal. Overall complication rate was low (<2%). There was no increase in risk of bleeding, even in subjects receiving anti-platelet therapy; only one of the 49 patients (2%) had a minor bleeding complication. CONCLUSIONS: Outpatient TDC removal by trainees was successful and safe in the vast majority of cases (99%). We propose that TDC removal skills should be actively pursued and acquired by all nephrology fellows. This would expand the scope of practice for future general nephrologists and facilitate timely patient care.