#NephMadness 16: Let’s win it for the Fellows

It’s finally arrived, the fourth annual NephMadness has dropped with 32 new Nephrology concepts battling it out for the month of March to see who will be crowned champion. Fully referenced blog posts on each of the topics are available at AJKD Blog and an explanation of the event can be found here for our new participants. Essentially, it involves reading up on the content provided and deciding which Nephrology concepts win in head to head, knockout match-play. You may fill out your bracket (pick your winners) using our online tournament page until March 23rd.

I’m hoping this year the winning participant will be a fellow/resident (or SpR/SHO) or better still a group of trainees. Last year there was a trend towards fellowship programs coming together, debating the topics and matchups and making their picks as a team. This is a fantastic way to extend the free online medical content to real-world flipped classroom teaching sessions at your institution. I’d also love to see this extend outside of the US to SpR training programs in Europe, Asia and beyond. So I propose you enter the contest individually but also with your colleagues as a group. Eternal glory awaits!

#NephMadness 2015: It’s almost here

It’s almost March, time to fill out your bracket. No not college hoops, it’s time for the annual Nephrology SoMed educational phenomenon that is NephMadness. The brainchild of Matt Sparks and Joel Topf has grown legs in its 3 years of existence and now represents a highlight of the Nephrology #FOAM calendar.

NephMadness is a homage to the NCAA Basketball Tournament, March Madness, but instead of matching up college basketball teams, NephMadness throws some of the most important concepts in nephrology together to battle it out. This years theme is Nephrologys interaction and cross-over with other specialties. See the current editorial in AJKD by the NephMadness team for the complete low-down. The overall regions/specialties, each with 8 Nephrology topics, for 2015 are:

1.         Obstetric Nephrology

2.         Infectious Disease and Nephrology

3.         The Heart and Kidney Connection

4.         Nephrology and Nutrition

5.         Genetic Nephrology

6.         Critical Care Nephrology

7.         Nephrology and Vascular Surgery

8.         Onconephrology

The game will progress throughout March with winners and losers announced along the way via ongoing blog posts. My own (extremely biased) view is that the winner will come from the strong Genetic Nephrology region! Let us know what you think when the brackets are published on March 1 on the AKJD blog. Also follow along on Twitter using the hashtag #NephMadness.

Urine Microscopy and the Camera Phone

I had a breakthrough with my iPhone 3G camera. I've tried unsuccessfully several times in the past to take pictures of urine microscopy fields through the lens of the microscope and had just about given up until I came across this NEJM letter to the editor that claimed it was doable.

The trick is to hold the lens of the camera phone about half a centimeter to a centimeter away from the eye piece. I found I needed to turn the intensity of the microscope light source down quite a bit to avoid whiting out the image. It's a little tricky getting the field into focus but with a little practice is completely doable.

Above is an image I took of a granular cast in a sea of non-dysmorphic rbcs from a patient with ATN and foley trauma. As pointed out by the letter to editor one can take video to scroll around the slide so you can show your attending, housestaff or primary team who weren't there with you what the urine microscopy looked like.

ASN In-Training Exam: ASN and RFN Review Material

I took the MCAT with pencil and paper. Over 500 nervous sweaty pre-meds in one giant auditorium. Everyone was so tense I'm surprised there wasn't a spontaneous combustion. Ever since, it's been electronic standardized testing were you often find yourself sitting next to a random guy taking the food handling safety exam. Just not as dramatic.

This coming Thursday April 7th and Friday April 8th are the dates for the ASN In-Training Exam for Fellows. It's usually administered at your home institution so we'll probably avoid the food safety guy. If you're interested, there's a brief practice test on the ASN site along with the NephSap core knowledge questions for review.

From RFN, below are links to previously posted review questions.

Question: Water-1 (answer choices are at the top of the "Answer")
Answer: Water-1

Question: PD-1
Answer: PD-1

Question: Transplant-1
Answer: Transplant-1

Question: Hypertension-1
Answer: Hypertension-1

Question/Answer: Pregnancy
Question/Answer: Transplant

If anyone has any other useful online review sources share the wealth in the comments.

Interventional nephrology in fellowship training

Interventional nephrology is quickly becoming a sought after "subspecialty" of nephrology. However, many training programs do not offer a structured training program (as highlighted in this recent AJKD paper). Traditionally nephrology training is spent rounding in the hospital, clinic or the outpatient dialysis unit. Procedures, like temporary catheters, biopsies etc. are typically performed throughout these rotations. Little time during training is devoted to assessing malfunctioning fistula, grafts or placing tunneled dialysis catheters. As the job market for nephrology continues to be challenging (highlighted by the recent RBT article) having the necessary certification in interventional nephrology can be a valuable asset when applying for jobs. RFN wanted to know how much exposure nephrology fellows currently have in interventional nephrology?

Of the 73 respondents to our poll

• 52% stated that they had hardly any exposure. I'm not terribly surprised by this. Only 11 programs around the country have American Society of Diagnostic and Interventional Nephrology (ASDIN) accreditation. Only 3 of these are affiliated with University based programs. However, several programs offer training that are currently not accredited by the ASDIN.
• 23% of respondents felt that they just had an introduction to interventional nephrology.
• Only 23% indicated that they either had a fair amount (17%) or more than enough (6%) exposure to this growing field.
  

It is clear that finding a program with an adequate amount of exposure to interventional nephrology is difficult.  I will be interested to see how nephrology programs adapt and expand their current training programs to meet the needs of future nephrology fellows. For more information on how to obtain certification visit the ASDIN website (www.asdin.org). Let us know how your program is offering interventional nephrology training.

Up To Date: The Nephrology Textbook of Today?

The Poll Results from last week were relatively convincing: Up To Date is the most commonly used current reference system for rapidly obtaining nephrology knowledge, with 67% of respondents declaring Up To Date as their top source. I certainly used this a lot as a fellow, though I also tend to use the primary literature (e.g., Pub Med or a familiar review) a lot as well. Googling is common (and according to this 2006 NEJM article by Steinbrook, more journal articles are accessed via Google than Pub Med--not sure if this is still true). Up To Date has historical roots in nephrology, as one of its cofounders, Dr. Burton Rose, is a nephrologist and electrolyte guru, author of one of the premier acid-base/electrolyte texts which should really be required reading for all nephrology fellow.

New poll starts tonight.

New Year's Eve Poll Results

Happy New Year's Eve! I found the results of last week's poll to be surprising...well, I guess I shouldn't be too shocked to see that Nephrology Fellows won the "hardest working fellow in show business" award, being that this is a nephrology-related blog and individuals have a tendency to view themselves as being excessively overworked. Rather, I was shocked by the paltry showing of Gastroenterology Fellows, who in my opinion have a rather tough job at the three major hospitals I've done post-graduate training at (Penn, Brigham, & Mass General). It just seems like there is an endless supply of GI bleeders, and it's not uncommon that they'll get called in during the middle of the night to do a procedure. While Nephrology fellows get called in for dialysis, for the most part the labor involved should be relatively predictable (evaluate patient for need for dialysis, consent, place line, begin dialysis) compared to doing emergent procedures. In any case: most fellows work pretty hard, and my guess is that there is probably a greater variability amongst fellows within a given subspecialty than there are comparing different subspecialty groups with one another. Happy 2010 to fellows from ALL walks of life.

New poll question to jump-start 2010.

Happy Thanksgiving

One of the things I was definitely grateful for at this year's Thanksgiving table: I'm not on-call and can spend the holiday with my family! Best wishes to those renal fellows working hard on this holiday.

Poll Results from last week: there certainly appears to be some dissatisfaction with the ABIM Boards exam, with nobody rating it as a perfect test and most feeling that there is at least some room for major improvement. I wonder if the results would be different if the poll was carried out later, after scores come back (I have heard that there is a 90% first-time pass rate...)

New poll on acute interstitial nephritis is on the right...one of the real "gray areas" in nephrology these days.

Poll Results & Post-Boards Weariness

First things first:  last week's poll results showed that the majority of individuals were wary of using physician "Pay For Performance" as a strategy towards increasing AV fistula placement rates.  Proponents of this strategy (see editorial by Hakim and Himmelfarb in a 2009 KI article) would argue that linking AV fistula placement to some type of financial reward (or linking lack of AV fistula placement to some type of financial penalty, depending on your viewpoint) is the surest way to increase the AV fistula rate in the overall dialysis population.  Potential arguments against using a physician "Pay For Performance" strategy would include penalizing doctors who take care of patients with a lower success of achieving working AV fistulas and encouraging the placement of unnecessary AV fistulas, to name a few.  

So I took the boards yesterday, and I'm eager to hear what others thought of the exam.  Fair?  Frustrating?  Piece of cake?  My own view:  it's a hard exam, and not only because it requires 8 hours of concentration--like many of these ABIM exams, there are often 2-3 answers which seem like they could be right; the challenge comes in selecting the "Best Answer" according to whomever wrote the question.  Ever wonder how they come up with the questions?  Here is the ABIM's stated policy on how all their exams are developed.  This week's RFN Poll of the Week is Boards related.  

Results of Kidney Biopsy Poll

The results from last week's Poll of the Week are in, and in general, a majority of individuals (64%) felt that their training programs  did a good job of teaching them the art of the renal biopsy, while a significant minority (36%) felt that they were ill-equipped to perform biopsies at the end of their fellowship experience. Interestingly, there was an identical breakdown of those who felt that nephrologists' renal biopsy skills are still relevant (64%) compared to those who felt that it's okay to leave the biopsies up to the interventional radiologists (36%).  Here is another way to look at the results:

 

A 2008 CJASN article by Drs. Berns and O'Neill ("Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs") states that virtually all nephrology fellowship programs provide training in renal biopsies, with about half of those training programs providing the fellow with instruction in hands-on renal ultrasonography.  Interestingly, the number of biopsies required for "certification" in each program varies widely, from only two to up to fifteen, and very few professional guidelines exist which specifically address what should constitute adequate training for kidney biopsy.  

Check out the latest Renal Fellow Poll of the Week on the left, which has to do with the newly-proposed Kidney Allocation System (KAS).  Because the Poll widget only allows the question to be rather short, I had to radically simplify what the plan proposes--I openly acknowledge that the plan is more complex than making it "easier for younger patients to get transplants, but harder for older ones", so to read a more detailed description of precisely what the KAS plan is, you can click here.  

The Trials and Tribulations of the Renal Fellow

The readers of the Renal Fellow Network have spoken, and the answer is clear:  the most blood pressure elevating activity is catheter-related!  29% of fellows selected the first answer (the MICU nurse paging you to inform that your IJ catheter is malfunctioning), with the second answer (your program director asking you to pick up the slack by double-covering services) coming in a close second at 25%.  Thanks for voting and be sure and make your voice heard in our latest Poll of the Week on the right. 

Changes Coming to Renal Fellow Network...

Changes are afoot at Renal Fellow Network!

First off, we're going to feature a NEW CONTRIBUTOR to this blog!  Despite the blog's moniker of "Renal Fellow Network", it has not been as much of a "network" as I'd like, as I (Nathan Hellman) have been writing 100% of the posts.  As such, I'd like to welcome fellow Renal fellow Conall O'Seaghdha to the Renal Fellow Network!  He will be contributing posts on a regular basis, and I think having multiple writers will enhance the variety of the site.  

We're also going to try a NEW FEATURE:  The Renal Fellow Network POLL OF THE WEEK.  I intend to post a different question every Thursday, and readers can vote over the course of the week.  

Finally, I'm going to be tinkering with a NEW FORMAT over the next few days. I've tried to select a background such that the text automatically adjusts to the size of your open window, which should ideally prevent wasted space. We'll see how that ends up; I'm still a relative neophyte in the HTML coding world. The goal of the site will still be to deliver a brief and easily-digestible nephrology teaching point on a near-daily basis--a process which becomes more and more relevant to those of us eagerly awaiting the Nov. 18th Nephrology Boards exam! 

And that, my friends, is change we can believe in.

Thanks for reading Renal Fellow Network and for those of you leaving comments, thanks.

"The eGFR Consult"

Cool new resource for all those iPod/iPhone (or whatever your MP3 player or PDA of choice happens to be): the ASN Kidney News podcast series. I have been listening to these during days in the lab where I happen to be carrying out some mind-numbingly repetitive task.

The most recent podcast is a conversation with Dr. Richard Glassock of UCLA in which he discusses how he approaches "the eGFR consult", a term which refers to the increasingly common situation in which a primary care physician refers an elderly patient to a nephrologist based solely on an estimated GFR that is determined to be abnormal. Presently, many hospitals will report every creatinine with a calculated GFR value based on the MDRD; often, values below 59 ml/min/1.73 m2 will be "red-flagged" as abnormal. Particularly in low body weight elderly patients, a stable creatinine of "only" 1.2 or 1.3 may come back with an eGFR indicative of CKD.

Dr. Glassock makes the point that we may be putting too much faith in eGFR values. He states that there is poor correlation between eGFR and measured GFR in many instances, that the MDRD Equation by itself is presently unsuitable for approving decision about whether an individual may serve as a live kidney donor, and that we are still waiting for a more universal standardization of creatinine amongst labs.

CKD Stage 3, for instance, makes up a large percentage of the population deemed "CKD" based on current KDOQI guidelines. Yet only a small fraction of these patients will go on to develop ESRD. One potentially useful approach is suggested in Great Britains "NICE Criteria for CKD"--they subdivide CKD Stage 3 in to "A" (eGFR = 45-59 ml/min) and "B" (eGFR = 30-40 ml/min) groups, and furthermore give patients a label of "P-positive" or "P-negative" based on whether or not proteinuria is present. Not surprisingly, individuals who are Stage 3B-P+ have a very high risk of progression of their kidney diseases, whereas individuals who are Stage 3A without proteinuria apparently have no increased risk of reaching ESRD. I think most nephrologists realize this fact (that proteinuria is a useful way of risk-stratifying patients falling into the CKD 3 category), but perhaps modifying the criteria used by PCPs and other physicians might lead to more optimal nephrology referral patterns in the future.

Renal Transplant Fellowship

While the ACGME regulates the vast majority of post-graduate residencies/fellowships, there are a few exceptions. One of the notable ones is the rapidly evolving Kidney Transplant fellowship. Previously, nephrologists were certified as members of the kidney transplant community based on their experience, having met various criteria that were based primarily on past experience with kidney transplant patients; there were not official training programs in existence.

Since 1998, however, the ASN and the American Society of Transplantation (AST) began a joint effort to standardize the training of transplant nephrologists. Because the number of graduates of such programs is relatively small (only 29 in all of 2008, according to the most recent issue of Kidney News), they are not regulated by ACGME. However, there is presently an AST Accreditation Committee which has been charged with approving transplant fellowship programs as sanctioned training programs. I am not sure if it is currently absolutely essential to be trained under an officially licensed program in order to practice as a transplant nephrologist, but my guess is that eventually it will become the law of the land.

For a list of all the 49 AST-accredited transplant nephrology fellowships, click here.

Core Competencies

In 1999, the Accreditation Council for Graduate Medical Education (ACGME)--the organization which oversees all residency and fellowship programs in the U.S. and is responsible for their official status as a licensed training program--issued a list of 6 Core Competencies which need to be addressed in all training programs.  

Regardless of whether one believes this is a useful concept, any physician who plans to continue on in the realm of academic medicine will need to be familiar with this list.  For instance, during a site visit of my residency program, I was specifically asked by an observer whether or not I was familiar with the core competencies.  I imagine that my response wasn't that impressive.  Anyways, here's the list:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

This blog would probably fit best under the category of "practice-based learning and improvement."  

"The Match"

Beginning in the 2009, Nephrology became one of the final medical subspecialities (along with Endocrinology) to join the Medical Specialties Matching Program (MSMP), a division of the National Residency Matching Program, a.k.a. "The Match." Prior to this, individual nephrology fellowship programs had their own individual application process in which the decision to offer fellowship positions to applicants was highly variable. A recent article in CJASN describes the history of the Nephrology Match and how its adoption has been received by Nephrology Fellowship Program Directors (the article says that it has been received generally favorably).

Not every Nephrology Fellowship Program participated in the Match: 14 out of 135 programs ERAS-registered, Match-eligible programs declined to participate, citing "concern over losing local applicants to other programs, concern over waiting until June to lock in applicants, and concern over the number of potential applicant interviews" according to the CJASN paper.

A few other interestings statistics: Nephrology had by far the most foreign nationals (49%) successfully matching as first-year fellows than any of the other medical specialties (33% on average). Interestingly, of the 230 applicants who did not match, only 17 were graduates of U.S. medical schools, indicating that there is a real lack of interest by U.S. internal medicine residents to go into nephrology.

One measure of success of "The Match"--especially from the fellow's perspective--is what percentage of applicants got their first choice. About 62% of applicants matched at their first choice while about 82% of applicants matched within their top three. Also indicative of success was the fact that 95% of spots offered by Nephrology programs

Nephrology ranked fifth in the total number of applications, behind (in decreasing order of popularity) Cardiology, Heme/Onc, GI, and Pulm/Critical Care.