Subspecialty Focus Tracks During Nephrology Fellowship Training

In April 2022, the American Society of Nephrology (ASN) established an expert task force to examine training requirements in nephrology. The task force used the opportunity to also respond to changes occurring in the practice of nephrology, to "ensure nephrologists are prepared to provide high-quality care." In the task force's report,1Rosenberg ME, Anderson S, Farouk SS, et al. Reimagining nephrology fellowship education to meet the future needs of nephrology: a report of the American Society of Nephrology Task Force on the Future of Nephrology.Clin J Am Soc Nephrol. 2023; 18: 816-825https://doi.org/10.2215/CJN.0000000000000133Crossref PubMed Scopus (3) Google Scholar there was recognition that models for delivering kidney care have evolved but that "the educational continuum for nephrologists remains more static than other medical specialties." For that reason, the approach was to seek changes in fellowship training that would support the rapidly changing reality of nephrology practice. Appropriately, one of the key recommendations of the task force was that "nephrology must establish individualized pathways to provide opportunities for fellows to explore advanced specialized care and other career goals in more depth." There is a strong assertion that "the second year of nephrology fellowship training must be leveraged to establish individualized pathways." The idea was clearly to allow the second year of training to be used for greater flexibility, individualization, and subspecialty exploration. Eleven different subject areas were mentioned as areas to enhance fellowship education. In this article, we discuss this subject in greater depth. We review our nephrology fellowship program's subspecialty focus track program that has been in place since 2017. Our program is highly aligned with the task force's individualized pathways recommendation. Through our accumulated experience we have gained insight into the practical implementation and impact of the task force's recommendations that may be helpful to other fellowship programs. Traditionally, nephrology fellowships have trained fellows to practice as general nephrologists.2Sachdeva M. Shah A. Singh H. Malieckal D. Rangaswami J. Jhaveri K.D. Opportunities for subspecialization in nephrology.Adv Chronic Kidney Dis. 2020; 27: 320-327.e1https://doi.org/10.1053/j.ackd.2020.05.002Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The focus on generalized nephrology training was sensible because a nephrologist in practice was able to manage the broad range of kidney issues that they were confronted with. Over the past decade, however, with the advent of novel therapeutics and innovations in nephrology and other subspecialties, nephrology care has become increasingly complex. One example is the role of nephrologists in caring for patients with cancer. In oncology, rapid advances have occurred in the knowledge of renal complications of cancer. This, and the remarkable upsurge in cancer therapeutics, has necessitated the creation of the new field of onconephrology.3Gudsoorkar P. Sise M.E. Jhaveri K.D. Onconephrology: the growth of cancer-kidney connection.Adv Chronic Kidney Dis. 2021; 28: 391-393https://doi.org/10.1053/j.ackd.2021.12.003Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Similarly, numerous breakthroughs in cardiac medicine and cardiac surgery have run ahead of the capability of many general nephrologists and led Díez and Ortiz4Díez J. Ortiz A. The need for a cardionephrology subspecialty.Clin Kidney J. 2021; 14: 1491-1494https://doi.org/10.1093/ckj/sfab054Crossref PubMed Scopus (10) Google Scholar to propose the subspecialty of cardionephrology. These authors note that "current general nephrology training does not seem to be sufficient for covering the broad and rapidly evolving field of cardiovascular medicine." Similar advances in other areas of kidney diseases suggest that the general nephrologist may increasingly be reaching out to nephrologists with enhanced subspecialty knowledge for support with complicated patients. An argument may be made that with additional training, all nephrologists could keep pace with the rapid expansion in required knowledge. But the reality is that the number of physicians choosing to enter nephrology fellowships is currently limited and an increased length of training in this environment could be challenging or unattractive to potential candidates. The need for nephrologists with expanded proficiency in what may be considered subspecialty areas of nephrology is addressed by the ASN task force's call to "explore advanced specialized care" during fellowship, with individualized pathways. Similarly, Greenberg et al5Greenberg K.I. Pourafshar N. Choi M.J. Current trends and challenges in nephrology fellowship training: expansion of education in home dialysis, palliative care, and point-of-care ultrasound.Adv Chronic Kidney Dis. 2022; 29: 510-515https://doi.org/10.1053/j.ackd.2022.07.006Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar wrote about opportunities to improve fellowship training, noting, "The past several years have seen increased opportunities for subspecialization." In 2017, the results of an educational needs assessment survey were published. This survey of fellows found that respondents wanted more instruction in focused areas of nephrology. Specifically, they propose subjects such as home dialysis modalities, obstetric nephrology, and acute glomerular disease diagnosis and management during fellowship training.6Rope R.W. Pivert K.A. Parker M.G. Sozio S.M. Merell S.B. Education in nephrology fellowship: a survey-based needs assessment.J Am Soc Nephrol. 2017; 28: 1983-1990https://doi.org/10.1681/ASN.2016101061Crossref PubMed Scopus (59) Google Scholar Taken together, 2 parallel and highly related needs have emerged in nephrology. One is the need for enhanced subspecialty expertise in the nephrology workforce. The second is the opportunity in fellowships, as noted by the ASN task force, to increase the attractiveness of the field through individualized advanced specialty training during the second year of fellowship training. Creation of track systems within graduate medical training is not an entirely new concept. For example, since 2011, the American Board of Surgery has allowed residents to choose tracks in specific subspecialty fields during surgical residencies. Up to 6 months per year of training in the final 3 years may be in a voluntary subspecialty track. Klingensmith et al7Klingensmith M.E. Potts J.R. Merrill W.H. et al.Surgical training and the early specialization program: analysis of a national program.J Am Coll Surg. 2016; 222: 410-416https://doi.org/10.1016/j.jamcollsurg.2015.12.035Crossref PubMed Scopus (25) Google Scholar studied the program's impact on participating residents. Findings showed a significant increase in the first-time board pass rate compared to time-matched peers, as well as an increase in specialty-specific board pass rates. Surveyed program directors were found to have an 85% rate of satisfaction with the program. They did, however, allude to scheduling difficulties caused by the program but stated that, on balance, it was "worth it." Residents who were surveyed reported greater mentorship and independence, greater competence for practice, and high satisfaction rates with the program.7Klingensmith M.E. Potts J.R. Merrill W.H. et al.Surgical training and the early specialization program: analysis of a national program.J Am Coll Surg. 2016; 222: 410-416https://doi.org/10.1016/j.jamcollsurg.2015.12.035Crossref PubMed Scopus (25) Google Scholar Hariton et al8Hariton E. Freret T.S. Nitecki R. Hinchcliff E. Stagg A. Program director perceptions of subspecialty tracking in obstetrics and gynecology residency.J Grad Med Educ. 2018; 10: 665-670https://doi.org/10.4300/JGME-D-18-00096.1Crossref PubMed Scopus (10) Google Scholar reported on the potential value of subspecialty tracking in obstetrics and gynecology. In contrast to surgery, this was in anticipation of the introduction of tracks, rather than in surgery where programs were already in place. Surveyed program directors were generally in favor of the idea but raised concerns on whether the number of OB-GYN generalists might be reduced.8Hariton E. Freret T.S. Nitecki R. Hinchcliff E. Stagg A. Program director perceptions of subspecialty tracking in obstetrics and gynecology residency.J Grad Med Educ. 2018; 10: 665-670https://doi.org/10.4300/JGME-D-18-00096.1Crossref PubMed Scopus (10) Google Scholar In other words, the concern was that after doing subspecialty tracks during general residency, a greater number of OB-GYN residents would subsequently seek specialty fellowships. When comparing to nephrology, this may be less of a concern, since there are significantly fewer postfellowship options in nephrology than in OB-GYN. DePasse et al9DePasse J.M. Nzeogu M.I. Travers C. et al.Early subspecialization in orthopedic surgery training.Orthopedics. 2019; 42: e39-e43https://doi.org/10.3928/01477447-20181109-01Crossref PubMed Scopus (10) Google Scholar studied the emergence of subspecialty tracks during orthopedic primary residency training. The authors found that subspecialty training was occurring more frequently during residency and leading to more subsequent fellowship training. They concluded that "formalizing this early experience with specialization tracks during the chief year may be considered."9DePasse J.M. Nzeogu M.I. Travers C. et al.Early subspecialization in orthopedic surgery training.Orthopedics. 2019; 42: e39-e43https://doi.org/10.3928/01477447-20181109-01Crossref PubMed Scopus (10) Google Scholar Adams et al10Adams D. Bischof J. Larrimore A. Krebs W. King A. A longitudinal emergency medical services track in emergency medicine residency.Cureus. 2017; 9: e1127https://doi.org/10.7759/cureus.1127Crossref PubMed Google Scholar studied subspecialty training during traditional emergency medicine (EM) residencies. Specifically, they studied a subspecialty track in emergency medical services, an American Board of Medical Specialties–recognized subspecialty of EM. The authors noted that subspecialty training was becoming available at many programs during EM residency even before post-training fellowships. The authors found significant beneficial opportunities to subspecialty training during residency and suggested formalizing the subspecialty track. They did note the need for "additional data to validate the proposed benefits of track implementation in regards to resident experience and resident performance."10Adams D. Bischof J. Larrimore A. Krebs W. King A. A longitudinal emergency medical services track in emergency medicine residency.Cureus. 2017; 9: e1127https://doi.org/10.7759/cureus.1127Crossref PubMed Google Scholar These experiences, taken together, suggest that in several graduate medical education residencies and fellowships, there is a need for creating subspecialty training tracks. Nephrology fellowship programs seeking to implement the ASN task force recommendations on individualized advanced subspecialty training can benefit from the experience gained from these other specialties. In January 2017, we initially saw these needs evolving and considered the feasibility of creating and offering optional subspecialty focus tracks during nephrology fellowship. As we reviewed the Accreditation Council for Graduate Medical Education (ACGME) program requirements for nephrology, it was clear that it was possible to provide enhanced training encompassed within the 2 years of the nephrology fellowship. The question arose as to what subject areas would be best suited for advanced training. The same year, Rope et al6Rope R.W. Pivert K.A. Parker M.G. Sozio S.M. Merell S.B. Education in nephrology fellowship: a survey-based needs assessment.J Am Soc Nephrol. 2017; 28: 1983-1990https://doi.org/10.1681/ASN.2016101061Crossref PubMed Scopus (59) Google Scholar published their influential survey and fellowship needs assessment. Fellows reported several areas in which they would like additional training. We considered these subject areas in the context of where we had faculty expertise. As a result, we identified several initial subspecialty focus tracks, including glomerular diseases, onconephrology, obstetric nephrology, medical directorship of dialysis centers, and clinical trials. We also subsequently created a track in transplantation, not with the intent to be as comprehensive as a full American Society of Transplantation–accredited kidney transplant fellowship year. Rather, as with all our focus tracks, the goal was to develop an enhanced level of proficiency and expertise. We decided that the subspecialty tracks could best be placed during outpatient and research months in the second year of training. In the subsequent ASN task force report it is stated, "The second year of nephrology fellowship training must be leveraged to establish individualized pathways." We agree with this, although it is important to ensure that general nephrology proficiency has been well established by the individual fellow during the first year of training. We felt certain that the development of dialysis competency could still be readily achieved (ACGME requires 4 months of experience with dialysis therapies). Similarly, we provide substantial flexibility and opportunities for fellows to be involved with research and other scholarly activities. With the publication of the ASN task force report, it was clear that our subspecialty focus track program was almost identical to the key second recommendation in the report, which was to implement advanced specialty training with individualized pathways in the second year of fellowship. This provided a unique opportunity to review our actual practical experience in the program to date. Details of our glomerular diseases subspecialty focus track program are available in the supplementary material (Box S1). To date, we have had fellows participate in tracks in onconephrology, glomerular diseases, transplant nephrology, obstetric nephrology, and medical directorship of dialysis centers. Fellows who have successfully completed subspecialty focus tracks have consistently expressed a high level of satisfaction with their experiences. Fellows described pride in their expanded knowledge and expertise and a strong sense of interest from potential employers. Box 1 discusses the criteria and model for our tracks system.Box 1A Blueprint for Nephrology Subspecialty Focus TracksTabled 1DefinitionA program that offers current nephrology fellows the option of choosing a nephrology subspecialty subject to devote significant time in the second year of fellowship to develop enhanced expertise, competency, proficiency, and knowledge.EligibilityFellows progressing well on competency-based goals and objectives.SubjectsGlomerular diseases, onconephrology, obstetric nephrology, kidney transplantation, kidney stones, cardionephrology, hypertension, home dialysis, medical directorship of dialysis centers, and clinical trials.Duration6-18 months, most often 12 months in the second year of fellowship.Placement in fellowshipFlexible. ACGME requires 12 months of clinical experience. The requirement for only 4 months of dialysis therapy exposure and variability in scholarly activities makes dialysis and research months an opportune time to place track activities. Care must be taken that the fellow does not lose any needed core educational time.ActivitiesVaries by track. Monthly meeting with track director, increased clinical exposure to subject material. Expectation for journal clubs on the track subject, a grand rounds–style lecture, curriculum lectures led by fellows, and scholarly activity focused on track subjects.EvaluationDirector/mentor evaluates fellow's progress and fellow evaluates track, providing feedback for program improvement and revision as needed. Open table in a new tab Tabled 1DefinitionA program that offers current nephrology fellows the option of choosing a nephrology subspecialty subject to devote significant time in the second year of fellowship to develop enhanced expertise, competency, proficiency, and knowledge.EligibilityFellows progressing well on competency-based goals and objectives.SubjectsGlomerular diseases, onconephrology, obstetric nephrology, kidney transplantation, kidney stones, cardionephrology, hypertension, home dialysis, medical directorship of dialysis centers, and clinical trials.Duration6-18 months, most often 12 months in the second year of fellowship.Placement in fellowshipFlexible. ACGME requires 12 months of clinical experience. The requirement for only 4 months of dialysis therapy exposure and variability in scholarly activities makes dialysis and research months an opportune time to place track activities. Care must be taken that the fellow does not lose any needed core educational time.ActivitiesVaries by track. Monthly meeting with track director, increased clinical exposure to subject material. Expectation for journal clubs on the track subject, a grand rounds–style lecture, curriculum lectures led by fellows, and scholarly activity focused on track subjects.EvaluationDirector/mentor evaluates fellow's progress and fellow evaluates track, providing feedback for program improvement and revision as needed. Open table in a new tab Our subspecialty focus track program starts at the beginning of the academic year. All incoming first-year fellows are made aware of the optional tracks. It should be noted that in a time where recruitment of nephrology fellows can be challenging, many of our potential applicants were aware of the tracks program and asked questions about it. The opportunity to pursue tracks is also reviewed with all fellows during monthly fellowship meetings. Fellows interested in participating in an offered track are encouraged to inform the program director at least 3 months before the end of their first year of fellowship training. This provides sufficient time for the program to create individualized track experiences and adjusted second-year schedules. Soon after the fellow expresses interest in a track, the track director or mentor meets with the fellow to review the curriculum. Only fellows in good standing in the fellowship and progressing well on competency-based goals and objectives are allowed to take part in the program. Fellows participating in the subspecialty focus tracks meet with their track director at least once a month to review their progress. In any given month the fellow may have no track involvement if they are on a consult or other hospital rotation. In track months, the activities vary greatly depending on the subject. The glomerular disease track (Box S1) is an example of enhanced activities. Fellows spend increased time working with glomerular center faculty in the longitudinal management of patients with a broad spectrum of glomerular diseases. Fellows also spend time in rheumatology clinic to obtain a broader view of lupus disease management. Five half-day sessions with nephropathologists enhance kidney pathology knowledge. There is required reading and other self-directed learning. The fellow's required journal club sessions must be on glomerular disease topics. In addition, the fellow is required to give a grand rounds–style talk on a topic in the field during their second year of fellowship. Scholarly work varies based on the fellow's interests, but there is a requirement for at least 1 contribution on glomerular disease: a case report, participating in a trial, or presentation at a national meeting. Fellows in all tracks are expected to maintain a log demonstrating their participation in the required (clinical and educational) activities. The fellow undergoes evaluation and also works with program leadership to refine and continually improve the focus track as needed. Upon successful completion of the track requirements, fellows are provided a certificate of completion prior to graduation. The certificate's purpose is to document the enhanced training, which can be shared with potential employers. Fellows who have participated in our subspecialty focus tracks have found a wider range of job opportunities prior to graduation. All past fellows who underwent subspecialty track training in our program are currently practicing primarily in their subspecialty of interest, either in the academic or the private practice setting. In our experience, the benefits of providing additional optional focused subspecialty track training to interested nephrology fellows include the following:(1)Interest in nephrology as a career remains low.11Pivert K. AY 2020 Nephrology Match: Preliminary Analysis—ASN Data Brief.https://asndataanalytics.github.io/AY-2020-Nephrology-Match/Date: December 4, 2019Date accessed: February 4, 2023Google Scholar Providing opportunities to train in emerging and exciting nephrology subspecialties (such as onconephrology, glomerular disease, cardionephrology, obstetric nephrology, critical care nephrology, palliative care, transplant nephrology, and interventional nephrology) without extending the length of training can enhance interest in nephrology careers among medical students and internal medicine residents.(2)The enhanced subspecialized training and expertise may expand employment opportunities by increasing the attraction of candidates to their potential employers. This can have the secondary benefit of increasing the attractiveness of both individual training programs and nephrology as a field of study.(3)Subspecialty expertise builds confidence and can enhance career satisfaction.(4)Adding subspecialty training fulfills the growing need for nephrologists with subspecialty expertise.(5)Subspecialty training can be accomplished within the existing 2 years of fellowship without adding a third year. The ASN task force recommends leveraging the second year of training for the purpose.(6)Core faculty members with expertise in an area have an opportunity to further develop their knowledge base, and enhance their leadership and mentorship skills. We have observed a sense of fulfillment among faculty members who have served as subspecialty track mentors.(7)There is the potential for increase in nephrology board pass rates, based on experience in other fields (though this remains to be seen in nephrology).(8)For selected individuals, a potential interest may develop where the fellow will choose to pursue a postfellowship formal year of additional training (like transplantation or other accredited fellowships). In addition to the opportunities created by subspecialty focus track training, there could be several challenges before and after implementation of subspecialty tracks. These challenges include the following:(1)There is a need for core faculty members who possess a strong interest and expertise in the subspecialty subject matter.(2)Availability of a relevant patient population at the training institution is required.(3)Fellows' rotation schedules need to be modified or revised and program directors must ensure that fellows undergoing subspecialty track training do not sacrifice training in core nephrology requirements.(4)Candidates who are not progressing satisfactorily may not be able to undertake the "deeper dive" of the focus track journey.(5)The program and track directors and core faculty members may need additional protected time for creating, implementing, and managing subspecialty focus track training programs.(6)Smaller nephrology programs may have difficulty creating subspecialty tracks. Hence, implementation of subspecialty tracks could favor larger fellowship programs.(7)There is a lack of data on the effectiveness of subspecialty individualized training in nephrology. Programs considering subspecialty tracks will need to rely upon the rationale as put forth by the ASN task force and data collected from other fields of medicine.(8)Subspecialty tracks could lead trainees to move away from general nephrology. We think this is unlikely, as most nephrologists would be expected to continue to see patients with general nephrology problems.(9)The most important challenge relates to the interest of fellows. As of the 2022 nephrology match, interest in the field remains at historically low levels. It is possible that many physicians entering nephrology fellowships may seek an easier path to fellowship completion than the subspecialty tracks offer. This, however, has not been our experience. Rather, we find that interest is mixed. Approximately one-third of our fellows have been seeking subspecialty training most recently.(10)Finally, if subspecialty training is adopted more broadly among US (and other) training programs, there will be a need to ensure that programs are of consistent high quality and that some degree of standardization is achieved among training programs. It would probably be within the realm of existing regulatory bodies to develop such standards and requirements for subspecialty track training during fellowship. After implementation of subspecialty tracks, we suggest using a focused evaluation process and in-training examination results in conjunction with other measures of general nephrology competence. The recommendation of the ASN task force for leveraging the second year of training to create opportunities for more advanced specialized training is a clear recognition of the contemporary needs of nephrology training. We believe that fellowship programs should consider creating more individualized pathways to meet the career goals of fellows who will be entering the increasingly complex field of nephrology. Based on our experience with subspecialty focus tracks, we believe that the ASN task force's recommendation for individualized pathways is absolutely feasible and a highly rewarding endeavor for selected, motivated trainees. Additional data, however, is needed and we recommend formal study of the effectiveness of advanced specialty training during nephrology fellowships. Hitesh H. Shah, MD, Steven Fishbane, MD, Daniel W. Ross, MD, MPH, MESc, Kenar D. Jhaveri, MD, and Mala Sachdeva, MD. None. Dr Shah is the Director of the Nephrology Fellowship Program at Zucker School of Medicine at Hofstra/Northwell and serves as a member on the American Society of Nephrology (ASN) Data Subcommittee. Dr Jhaveri reports consultancy agreements with Secretome, George Clinicals, PMV Pharmaceuticals, and Calliditas Therapeutics; is a founder and co-president of the American Society of Onconephrology (ASON); and has received honoraria from the American Society of Nephrology and UpToDate.com. The remaining authors declare that they have no relevant financial interests. Dr Jhaveri has served on the editorial boards of CJASN, AJKD, CKJ, Journal of Onconephrology, Kidney International, and NDT; has served as Editor-in-Chief of ASN Kidney News; and has served as section editor for onconephrology for Nephrology Dialysis Transplantation. Received February 16, 2023. Evaluated by 3 external peer reviewers, with direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form May 5, 2023. Download .pdf (.07 MB) Help with pdf files Supplementary File (PDF)Box S1