Procedures in Nephrology Fellowships

Abstract

In this month's issue of CJASN , Berns and O'Neill describe the results of a survey of US adult nephrology training program directors (68% responded) on procedures performed by faculty and fellows at their institutions (1). The results are not surprising: The vast majority of programs require competence in performing native and transplant renal biopsies and placement of temporary hemodialysis access, whereas approximately 15 to 20% of programs perform tunneled catheter placement, peritoneal dialysis access placement, and/or therapy of stenosed/clotted vascular access. As one might expect given the lack of nationally mandated standards, there is no uniformity among programs on the required number of a given procedure. What is surprising is that such analysis of training program practices has not been done for 18 yr (2). Even more concerning is that there has been no analysis for 17 yr on the effectiveness of procedural training in preparing fellows to be practicing nephrologists (3). What, then, should renal fellowship programs be doing, and how do we make this determination? Certain procedures are generally accepted as being integral to nephrology practice; relinquishing them would potentially affect the timeliness, quality, and safety of patient care. Such procedures are appropriately mandated by the American College of Graduate Medical Education (ACGME): Renal biopsy and temporary hemodialysis access. The latter is obvious: Nephrologists should have the ability to place emergent access. With regard to renal biopsies, only nephrologists can make real-time decisions about adequacy of sample size given the suspected diagnosis. Nephrologist-obtained renal biopsies yield similar numbers of glomeruli but fewer severe complications, as compared with radiologists (4). Scheduling conflicts may preclude timely …