A mid the rising demand for nephrologists and declining numbers pursuing the profession, a more expansive nephrology elective for medical residents at a Long Island, NY, health system was designed to help reset the balance.
“I think the elective is exactly what they need,” said Mitchell Rosner, MD, when asked if the new elective created by nephrologists at Hofstra North Shore–Long Island Jewish (LIJ) School of Medicine is good for residents. Dr. Rosner is Professor of Medicine and Chair of the Department of Medicine at the University of Virginia School of Medicine.
“I think the goal is to broaden the experience in order to better typify what a nephrologist does and expose students to the breadth and depth of nephrology practice.”
Nephrology electives have traditionally focused on inpatient care.
“What residents see are patients who are critically ill with acute kidney injury or in the hospital with some complication of their end-stage renal disease,” said Jeffrey Berns, MD, Assistant Chief of the Renal Division and Director of the Renal Fellowship Program at the Perelman School of Medicine at the University of Pennsylvania.
“It is not an experience that necessarily will grab you by the lapels and say this is something that you are going to love doing for the rest of your life.”
The restructured elective, on the other hand, incorporates outpatient practice, as detailed in a study published online ahead of print by the American Journal of Kidney Diseases.
“We feel it provides a more complete picture of nephrology for the residents in training,” said lead author Kenar D. Jhaveri, MD, Assistant Professor of Medicine at Hofstra North Shore–LIJ School of Medicine and one of the creators of the new elective.
“Teaching them about peritoneal dialysis, transplants, glomerular diseases, and stones is important, and I think the outpatient experience enhances their knowledge and exposes them to the nephrology field as a whole.”
During a 24-month period, 40 medical residents from the North Shore–LIJ Health System's two tertiary hospitals, LIJ Medical Center and North Shore University Hospital, were randomly assigned to either a traditional nephrology elective or the redesigned elective.
After the elective, 32 residents—21 from the traditional elective and 11 from the new elective—completed a survey about their experiences. Of the residents who participated in the revamped elective, 86% reported that they would consider a career in nephrology, compared with 50% of the residents who followed the traditional elective.
In addition, 80% of residents who completed the redesigned elective also thought they came away with a grasp of nephrology that they might not have gotten from the traditional elective.
“This is a single-center study that included both centers,” Dr. Jhaveri said. “We did not have enough numbers to do any statistical analysis, but I agree that larger studies are needed to confirm the results.”
Larger studies also could assess how generalizable the elective is.
“Institutions are different and have different experiences and clinic setups,” Dr. Rosner said. “I think the specifics may vary in different places, so testing it out will be important. It's going to take many years to know whether this is going to work.”
In addition to offering exposure to outpatient care, the new elective also provided an opportunity for residents to complete a creative project by the end of their nephrology rotation, which the authors hoped would spark enthusiasm and passion for nephrology. Such projects could use social media, concept maps, or games to improve education.
This aspect caught the eye of Mark G. Parker, MD, Program Director of the Nephrology Fellowship at Maine Medical Center and Chair of the American Society of Nephrology (ASN) Workforce Committee.
“I think that is very innovative, and that little piece is not really done anywhere,” Dr. Parker said. “We can all offer our residents exposure in these areas of nephrology, but adding this twist of trying to use creative teaching tools and exposing residents to that is nice.”
The Curriculum Subcommittee of the ASN Workforce Committee has circulated a survey through the Association of Program Directors in Internal Medicine to learn about the current practices of residency programs across the country.
“Dr. Jhaveri's article refers to the fact that many residents only have an inpatient exposure to nephrology, with a lot of exposure to chronic illness and complex illness,” Dr. Parker said. “That's our sense of what's probably the case, but we don't really know.”
While the survey results will provide more information, Dr. Parker's sense is that this restructured elective is not unique, he said.
“I do think there are probably people doing things similar to what Dr. Jhaveri is doing.”
Still, he applauded the systematic creation of the elective and the decision to study its effects.
“There is not anything I don't like about it,” Dr. Parker said. “It's sort of like mom and apple pie; what's not to like? Definitely anything that gives our medical residents a broader view of opportunities in nephrology can only be good.”
Mentorship, Mentorship, Mentorship
The new elective facilitates a factor shown to be a leading driver of enthusiasm for nephrology—inspirational mentors.
“The residents interacted with more than three faculty members in their entire month as opposed to just one to two faculty members in the pure consult elective,” Dr. Jhaveri said. “This increased amount of faculty exposure can generate a possible mentor-mentee relationship.”
Deepa Malieckal, MD, a third-year medicine resident at North Shore–LIJ who is applying for a nephrology fellowship, participated in the traditional elective first and then in the restructured elective once that had been instituted.
“This new elective kept me engaged during the entire time,” Dr. Malieckal wrote in an e-mail message. “I learned a lot and found it fun to be able to interact with physicians and patients from all parts of the field. It made me love the field more, and I can see this elective influencing more people to choose nephrology as a specialty in the future.”
The nephrologists interviewed for this article also credited outstanding mentors as a leading reason why they pursued the profession (see the below box).
“I think on a national level we need to recognize and celebrate those mentors who are exceptional,” Dr. Rosner said. “Award them; recognize them; set them up as more national role models, and recognize this as a pathway to career success.”
Another step for the future is to look not only at how nephrology electives influence interest in the field, but also how they affect residents' comfort level with different aspects of care, Dr. Jhaveri said.
“I think bigger centers, multi-centers, should really evaluate how they are providing education in the consult arena and whether residents are satisfied with the program. A service-based culture should move to an education-driven elective culture.”
Listen In Online
Tune into the Nephrology Times website at http://bit.ly/NTPodcasts for two new podcasts: Kenar D. Jhaveri, MD, and Hitesh Shah, MD, discuss the new nephrology elective they helped create, and prominent nephrologists share what sparked their passion for the field.
Why I Become a Nephrologist
Nephrologists who now are actively involved in the education of medical students, medicine residents, and nephrology fellows thought back to their own residencies, chiming in on what made them choose nephrology.
I think it was a couple of things. One was an outstanding mentor. Of the people whom I thought were the smartest, greatest clinicians when I was a medical student, two of them were nephrologists, and those were the people I wanted to emulate the most. The second was the complexity of the subject matter and the challenges of taking care of very complex and ill patients, and trying to improve their quality of life. I thought that was something that was stimulating and something that could keep me engaged for a career. I also thought that it was the specialty where the physiology translated into the clinical care of patients the most, so that if you really understood the basic science of physiology, you could use it at the bedside.
—Mitchell Rosner, MD Professor of Medicine, Chair of the Department of Medicine, University of Virginia School of Medicine
For me, there is a mix of physiology, which I enjoy thinking about; critical care, which I enjoy doing from a clinical perspective; and I enjoy the outpatient outcomes of nephrology. It gives me a broad spectrum of different activities clinically and an underpinning of being able to apply basic physiology to clinical medicine.
—Jeffrey Berns, MD Assistant Chief, Renal Division, and Director, Renal Fellowship Program, Perelman School of Medicine at the University of Pennsylvania
I found the physiology—not just that, the pathophysiology—interesting. I do agree that some people I met were interesting, challenging—really good doctors who seemed to understand humans and disease, so you want to be like them. I was lucky to have good mentors. Finally, I would say I was pretty confident I would have a job; this is a condition that inflicts a lot of people. I have no regrets at all.
—Aaron Friedman, MD Vice President for Health Sciences, Dean of the Medical School, University of Minnesota
It was the mentors for me. I did my fellowship training at Tufts, and there were some outstanding nephrology mentors. I had been a resident there, and they got me excited. Once I was a fellow, they shaped my career.
—Mark G. Parker, MD, Program Director, Nephrology Fellowship, Maine Medical Center; Chair, American Society of Nephrology Workforce Committee
For me, it was mentors. I was really inspired by a renal pathologist in my medical school, Paul Shanley. Following that in residency, mentors showered the enthusiasm for nephrology, and that confirmed my interest in medicine. I want to take the time to thank Paul Shanley, John Forrest, Mark Perazella, and Aldo Peixoto for inspiring me to do this wonderful field of medicine.
—Kenar D. Jhaveri, MD, Assistant Professor of Medicine, Hofstra North Shore–LIJ School of Medicine, and a creator of North Shore–LIJ Health System's new nephrology elective